Feature / The whole picture

It is often said that the NHS is awash with information. It certainly generates a lot of data and, while useful as standalone facts and figures that can shed light on overall financial position or inform a staff roster or to record a patient has been given a course of antibiotics, there is a belief that more could be done with this information. Many call this ‘operationalising’ the data – turning raw data into information that can be used to ensure the organisation runs efficiently, delivering high-quality care.

It is a way of engaging frontline staff in suggesting ways to make services better for patients and more efficient and realising the financial impact of decisions. Presenting this information in a clear and accessible way is critical to achieving this engagement and NHS organisations are increasingly using dashboards to get across the message.

Often the dashboards are bought in as off-the-shelf solutions and adap

ted to trusts’ needs, but several trusts and commissioning support units have developed their own business intelligence tools, which they are now selling to their peers.

Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) has developed a number of leading edge business intelligence applications or apps to turn raw data into real-time visual insight. Healthintell, a partnership between the trust and NHS Shared Business Services (SBS), is offering these to the wider NHS. Rob Forster, WWL’s deputy chief executive and director of finance and informatics, says the trust began developing the platform in summer 2014, partly through necessity.

‘We realised that we needed the engagement of our staff in all aspects of the business,’ he says. ‘As with many other trusts, we weren’t using technology to its maximum, and improving the two things worked together really well. Healthintell allows individuals to manage their work in real time using reliable, accurate information. It has transformed the way we do things and gives a line of sight from boardroom to ward.’

Mark Singleton, head of business information, says pressure on A&E – even in summer – also prompted the initiative. Over two months, clinicians and managers pared down the information doctors and nurses needed to improve the efficiency and performance of A&E. This was then developed into an app. A large touch screen in A&E (pictured above), the chief executive’s office and elsewhere in the trust shows the latest position.

Since its introduction and over 12 months of refinement, seasonally comparable patient waits have reduced by an average of 30 minutes in A&E, and the trust wants to make further reductions.

‘We feel some of our success is attributable to the use of the technology. For example, we cover the greatest population in Greater Manchester – around 320,000 people – and we have the lowest number of beds per 10,000 population,’ Mr Forster says.

Despite this, to date this year we are the one of the few trusts achieving the 95% A&E target and in the top 10% both regionally and nationally. There will be a range of reasons for that, but some will be due to the way we use technology.’

The app has some rules built in and helps facilitate work across the health economy, which is the basis of the local approach. For example, if a patient who was recently discharged presents at A&E, the trust community access team is alerted. This alert goes out once they register at A&E, rather than when they are triaged or seen by a doctor. It means the access team can see the patient sooner and put together an appropriate package of care and support.

There are financial benefits – fewer breaches of the A&E target mean performance fines are reduced. The benefit from the penalties alone pays for the investment in the tools, Mr Forster says.

‘There is a real thirst for data and transparency in the NHS at the moment,’ says David Morris managing director of WWL’s partner NHS Shared Business Services. ‘This is a good example of a board being able to see, in a clear way, a dashboard of what’s happening in A&E. It allows them to understand the pressures in their organisation, monitor the pinch points and manage workflow more effectively.’

Using Qlik

WWL’s Healthintell uses Qlikview to gather and present information. David Bolton, Qlik healthcare industry director, says more than 150 NHS bodies are using Qlik, deploying the firm’s products mainly in finance. ‘This is largely due to the pressure on health organisations to make better use of technology to improve efficiency and reduce costs,’ he says. ‘There is an acceptance that better use of data can improve efficiency. Qlik is about enabling health organisations to explore their data – clinical, financial or operational – and it’s usually a combination of all three. We are engaging staff to interrogate data, which can lead to improvements in care, reduction in costs or a higher volume of patients.’

Qlik allows NHS organisations to combine data from several sources, which in an acute trust could be 30 or 40 different systems. ‘The challenge is moving from a silo reporting approach to something that provides them with the whole picture. It allows them to see the impact of an action across the organisation.’

On the Qlik platform, Qlikview is the main app in the NHS and is often used for patient-level costing. Qlikview, and its sister app Qlik Sense (which has a greater emphasis on self-service), use an associative model that links data from multiple systems.

For example, a look into variations in the cost of knee replacements could compare the ‘profit and loss’ by surgeon. A number of surgeons could cost more than others, but the system would help to identify the variation, across all the available data sources. The surgeons may use the same prostheses as their colleagues, ruling out one possible cause of cost variation, but their patients spend more time in theatre, have a longer length of stay or a greater chance of readmission. They may need a refresher course to bring them up to best practice and reduce theatre time, length of stay or many other factors. Qlik enables clinicians and managers to see the whole story across their data, rather than relying on individual system reports, says Mr Bolton.

One of the largest trusts in the country, East Kent Hospitals University NHS Foundation Trust, has also developed its own platform to provide real-time data. To spread its use, it has formed a company, Beautiful Information, which is 50% owned by the trust and the Kent, Surrey, Sussex Academic Health Science Network. It is currently being used in several other NHS trusts.

Mobile phones

Director of information Marc Farr, says the initiative sprung from the trust IT department. Information is provided on users’ mobile phones, showing, for example, performance in the emergency department in real time or the trust financial position. The East Kent trust also uses Qlik tools – for trend analysis, for example – using data from its platform.

Dr Farr (PhD) says a lot of business information tools are available to the NHS, but they can be expensive so the trust decided to build its own mobile platform.

Apps sit on the platform, which acts like an operating system such as Windows. One app, Operational Control Centre (pictured left), is refreshed every two minutes and gives users an overview of the emergency departments across the trust’s three sites. The information includes: how many patients are in the department; average waiting time: how the department is performing against the four-hour A&E target; delayed transfers of care; and availability of clinical decision unit beds and how many will be needed in the next hour.

‘There’s no duplication or double entry as all the information is pulled from existing databases. If you go to A&E and are admitted, the apps will pull the information about you from the database behind the patient administration system,’ says Mr Farr.

‘We push the same information to our wider clinical colleagues, so they can see on their phones how we are doing in terms of referrals and A&E performance. If we are doing really well on one site and struggling on another, there may be things local GPs can do to help.

‘A couple of years ago, trusts were quite closed about their data, but in the current financial climate it is not about taking as much money from clinical commissioning groups as you can; it’s about the whole health economy.’

A second app, Activity and Finance Tracker (AFT), compares current activity and income against plan. It is updated every two hours. ‘If you said you would do 100 knee replacement operations by a certain point in the year, but had only done 95, it will prompt the team to catch it up – by doing a Saturday list or a three-session day, for example,’ Dr Farr says.

‘The app takes the average price for each operation, outpatient appointment or A&E admission and multiplies by activity. If you are, say, 2% behind on day cases, the finance director may look at that and pick up the phone to the head of surgery to say we need to get cracking.’

Average price is sufficiently accurate on which to base near real-time management decisions, he says. Traditionally, this information would be generated about once a month and Dr Farr adds that although it is high-level, the AFT allows managers and clinicians to act quickly and ensure the trust operates smoothly.

Healthintell app

Healthintell also has its own finance app, Devolved Financial Management (DFM). DFM has customer (budget holder) and finance department facing views. ‘Both have the same information, but the difference is in how it’s portrayed,’ Mr Singleton explains.

‘While the finance information is in real time, the budget holders see more historic information on a monthly basis. This allows the accountants to make the accruals and adjustments needed and means the budget holder is not presented with something that does not take everything into consideration.’

The budget holder interface offers easy to understand financial performance information – spend against budget for the last month and year-to-date, for example. Those achieving their budget have a green smiley face and red if overspent (these were suggested by users). ‘It highlights problem areas and the biggest variance against plan; what’s causing problems in their budgets,’ says Mr Singleton.

Going deeper, they can view a more traditional expenditure statement view, with pay broken down to Agenda for Change levels. In the non-pay section, there is flexibility to drill down to invoice or transaction level.

‘The app was introduced half way through the 2012/13 financial year and in the six months that followed, the number of green budgets increased by 12% – the equivalent of £2m improvement in that short period,’ he says.

The finance view shows which budget holders are using the app and which are not. It also takes some of the legwork out of financial reporting by automatically generating a set of standard spreadsheets. Accountants played a key role in deciding on these. ‘This frees up their time so they can engage with their clinical divisions, offering their support on service redesign, writing business cases or on costing exercises,’ Mr Singleton says.

Gone are the days of divisional accountants meeting with budget holders each quarter to pore over their budget position on A3 sheets. These have been replaced by regular ongoing team business catch-ups. This reflects the speed of change and team solution approach required in the NHS today, as opposed to accountants being seen as simple bean-counters providing reams of numbers once per month, he adds.

Some of the information offered in the Healthintell dashboard is reflective – what happened yesterday or last week. But Mr Singleton believes it has been a success at WWL because of its ability to offer real-time data and its capacity to predict future A&E demand. ‘When we started looking forward, we realised we had a challenge – how do you take the unpredictability out of emergency care?’ The system can predict, to a degree of around +/- 5%, the demand on A&E in the next few hours, next week or next month.

Again, the trust involved clinicians from the start and all the way through (using agile development) to iron out potential problems. Even now, the app is enhanced regularly. The predictive element of the app uses data from several sources, including historic and recent data. Although as yet it doesn’t link to an e-roster, it is used when planning staffing of wards and departments.

Both Healthintell and Beautiful Information use data already collected by the trust – for example, what is used for commissioning data sets. Mr Singleton says: ‘In the NHS we are focused on collecting data – trusts are swimming in volumes of data, but aren’t the best at putting it to use. This is about using information trusts already have.’

WWL is looking to extend Healthintell and its intelligence to wards – for example, gathering and presenting information on lengths of stay and delayed discharge.

Spreading usage

Dr Farr believes the principles behind the Beautiful Information platform and its apps can be applied to other parts of the hospital. The East Kent team is working on an HR app, which could present near real-time information on agency spend and mandatory training compliance, for example. Other developments could focus on referral to treatment times and an app to support integrated discharge.

There is nothing to stop other trusts developing their own tools based on existing software. Healthintell and Beautiful Information believe they simply provide a quicker route to the benefits. Mr Morris of SBS says his firm can smooth the introduction of Healthintell – its predictive element makes it distinctive. This can be tailored to trusts, with 80%-90% of sources of information common to all NHS providers. SBS and WWL hope to add parameters to make its forecasts more accurate.

Dr Farr says the advantage of Beautiful Information is that it has been developed by the NHS, for the NHS. It used agile development – asking clinicians and other users what they wanted; building it and then testing it with them to ensure it worked and met their expectations. ‘If another trust was to develop a system like this, it would have to have a decent database and development skills. It could take ages. But I think most trusts are sensible and see our development is a great idea.’

The NHS is embracing the power of business intelligence tools to present complex information, clearly, to all members of staff. Whether it is an off-the-shelf or bespoke solution, their use looks set to grow.