Interview with Mr Butt, consultant orthopaedic surgeon at RNOH about their digital transformation

Please tell me about the processes you (the Trust) had before Pathpoint? What were your challenges with this? Our department had a paper-based system where we were receiving referrals from GPs via e-RS, we were then having to print that referral, collate all the documents in one patient paper bundle, do paper based triage and once triaged, we uploaded to our EPR system.

To collect PROMs in our department we were using forms that we gave to patients depending on their triage outcome. So we would triage them in one of the categories for their particular sub-specialty and that would dictate the outcomes they would have in clinic and at 6 and 12 months.

For consent, we would do traditional paper based consent. The initial stage 1 would be done in clinic and some teams would have a consent clinic and others would do all the documentation on the day of surgery, which is actually limited in the information it conveys to the patient.

Now, using the Pathpoint e-referral system, we receive the e-RS referrals directly, as well as tertiary and internal referrals via the same system so they are all brought together in the same place and then we do a completely electronic triage. We still divide them in the same categories for our PROMs, but then our PROMs are delivered via the same system, so they are sent out to the patients automatically, including follow ups. We trigger the PROMs to be sent at different intervals appropriate to their surgery, which has streamlined the process.

In terms of consent, we haven’t started to use it fully yet, but we are in the development phase of the eConsent system which will be triggered at the point of listing someone for surgery. They will then be sent a consent form which is tailored to them and provides both generic and specific procedure based information for them to read independently. More information can be provided alongside the consent form such as leaflets and videos. Hopefully we will find an improvement in the quality and provision of information to patients preoperatively. Tell us a little bit about the drive behind the Pathpoint project (why Pathpoint and why digital, why now). There was an urgent need for PROMs data collection We had a solution which was at the end of life and that meant that we had to find an alternative. As a specialist orthopaedic hospital, we have a need to demonstrate our outcomes, as well as the outcomes relating to the complexity of surgery that we are doing. There are a large variety of solutions for PROMs data collection, but we also wanted to deal with some

of the other issues we were having, including referrals, as we were receiving from a range of different sources, with some urgent things coming via website and email, some via text message and telephone calls, as well as the referrals by e-RS and letters. And naturally, because of the disparate sources and a number of referral streams, there were some types of delays in getting the referrals formalised and onto our system, which stalled giving the patients their appointments. We wanted to streamline and improve the process, and have a more robust system so there is less chance of error. Moreover, during Covid, we had to minimise patient contact and do a lot more virtual consultations so the challenge was attaining the written consent in that environment. We also had the desire to improve the overall documentation of the consent process, to streamline it, so this brought it all together. We considered a number of options and Open Medical was able to provide a complete solution that covered all the areas we wanted.

Since launching Pathpoint, what difference has this made to the team and the likes of yourself? How has pathpoint improved clinician workflow? Patient experience?

It’s early for us to talk about the patient experience but, from the clinical workflow point of view, it has allowed us to view and triage referrals at any time and from anywhere. As we’ve introduced the system and evolved it to meet our requirements we are now reaching the point where we are hoping to remove most of the admin work from the workflow. At the moment there is still a manual process to link the different information sources together. On the PROMs side, which has now been fully implemented, we are seeing a good return rate on our PROMs. We also have immediate feedback, we know which patients have been sent forms, whether they have been returned, and where we need to work on improving return rates. It’s very useful to have that sort of live dashboard feed. Again, it’s a bit early for us to say how it’s working out in terms of PROMs following our procedures and the longer term outcomes, but it seems to be going well at this stage. Whilst I appreciate the project has only been running for a few months, can you please tell me what immediate benefits you noticed?

We have seen an instant saving in resources as we have stopped printing out and collating multiple documents across the Trust, drastically reducing paper usage. Moreover, the referral system can be a two way communication system. For example, some of my colleagues in other departments have used that function to communicate back and forth with the original referrer to request more information and to give treatment advice. That’s a complete change in the way referrals work and it’s an additional feature we wouldn’t have previously had and would have required an email or phone call. Now it’s all on one system in one place with clear documentation of what’s happening, as it’s all recorded.

How did this benefit the wider team and hospital in general?

The idea is that it reduces admin burden, whilst maintaining the same or better level of service. We are looking at the benefits realisation, but the hope is that it reduces the cost of printing, admin workload, errors, loss of paperwork and delays to treatment. What do you feel are the biggest challenges/barriers within digital transformation both at your Trust and generally in the NHS?

Although a digital solution may seem like it will bring a lot of benefits, implementing it and the change that’s required across the organisation from hardware and software, to people and training and just changing normal behaviours- that takes time and resources. There is always a lag between the need and the identification of the need and the implementation of the solution, during which time the situation can potentially change. During this process, we’ve seen something of an evolution of our requirements. As people get more and more engaged and they see and use the solution, then they realise that the requirements may be not quite what they initially outlined. There is this dynamic process of modifying and tweaking a system so that it meets the need, which is something we’ve been doing with the Open Medical team. What’s the ultimate goal with this project and what would you like to see in the future? What’s the digital utopia in your opinion?

What I'd consider as success is a system that achieves the goals of improving our referral management process, improves documentation of consent whilst reducing the clinician burden of the process of consent. We are hoping Pathpoint improves our outcomes data collection so that it can allow us to demonstrate our outcomes robustly with minimal internal management. If I’m honest, I haven’t considered the question of digital utopia carefully enough to give you an answer, but I think that it’s an infrastructure that sits with our day-to-day working, so my time is spent doing what I’m trained to do and the IT supports that. The patients feel as though they are included in the whole process, the communication is seamless and they are treated in a timely fashion to the highest standard- so the systems that are in place need to facilitate that.