National Pathology Programme - Digital First: Clinical Transformation through Pathology Innovation - NHS England
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National Pathology Programme Digital First: Clinical Transformation through Pathology Innovation
National Pathology
Programme
Digital First and the Call to Action
Digital First comes at a key time for the NHS, The need for transformation in models of delivery,
which treats around one million people every 36 focussing on producing great value care with the best
hours. One quarter of the population (just over outcomes for patients, has never been greater. Early
15 million people) has a long term condition such diagnosis to prevent premature mortality, care of long
as diabetes, depression, dementia or high blood term conditions, and acute care are all areas in which
pressure - accounting for fifty per cent of all GP pathology has an enormous role to play, not only in
appointments and seventy per cent of days in supporting clinical teams, helping design pathways, and
hospital. The number of older people likely to making results visible and interpretable for patients, but
require care is predicted to rise by over 60 per also in innovation to make the pathways faster and better.
cent by 2030. Hospital treatment for over 75s has
Pathology is leading the way in the use of digital
increased by 65 per cent over the past decade and
technology, with the automated disciplines at the leading
someone over 85 is 25 time more likely to spend a
edge. In cellular pathology I have seen the way in
day in hospital than those under 65. This increased
which my own practice has changed, to include order
demand comes at a time of financial pressure,
communications and electronic delivery of reports, bar
where modelling shows that continuing with the
coding of cases, use of electronic templates, voice
current model of care will lead to a funding gap of
recognition for complex narrative upload, electronic
around thirty billion pounds between 2013/14 and
requesting of addition special stains, SNOMED CT
2020/21.(1)
(Systematized Nomenclature of Medicine–Clinical Terms)
Preface by Professor Jo Martin
coding for both diagnosis and procedure enabling both There is huge potential for improvement in patient
tariff and research information to be gathered with ease, care through digital transformation of pathology, and
electronic referral and consultation from all over the globe this document highlights some of the opportunities
via email and image transmission, workload analysis, and and illustrates some of the many ways in which digital
most recently digital external quality assurance. I refer creativity and innovation in pathology can make a
to electronic resources, such as the Online Mendelian real difference.
Inheritance in Man database for information on the
rarer genetic conditions and I can access this, and the Prof JE Martin MA PhD FRCPath
latest literature, all from my desktop, laptop, tablet and National Clinical Director of Pathology NHS England
smartphone, and can access and complete the majority Professor of Pathology, Queen Mary University of
of my statutory and mandatory training needs in the same London
way. Data show that over 60% of the UK population and
more than 80% of the younger UK population now own
1. NHS Call to Action. http://www.england.nhs.uk/wp-
a smartphone. As technology and connectivity improves,
content/uploads/2013/07/nhs_belongs.pdf
we are moving to a position where the technology
becomes more and more invisibly integrated into
laboratory settings and in everyday care.
Digital First / Pathology / 1
Digital First Pathology Quality improvement in pathology in a digital age The Pathology Modernisation Programme and the Carter Review both recognised the need for a change of scale for pathology services. Although the initial focus was on internal efficiencies within the test production process, the same logic applies to innovative ways of using pathology services. Indeed a focus solely on local test production misses opportunities for pathology services to work in different ways to enhance care pathways, enable patients to take control of their chronic disorders and save resources outside the laboratory and across health economies. Where changes such as patient access to the results of their blood tests have been introduced, the main benefit has been in a reduction in the number of visits required by patients – the use of this innovation by Kaiser Permanante is a widely recognised example.
Foreword by Dr Ian Barnes
Using pathology services differently must be based on
improving quality of care as well as increasing efficency.
Pathology underpins the majority of clinical interactions
and clinical value chains can only be unlocked if
pathology services are coordinated in concert with clinical
services. The gains from digitisation described in this
report accrue when pathways are joined up across care
settings and clinical networks. Quality is a major part of
the equation in achieving value. Technology innovation
such as standardisation of pathology reporting through
the use of the National Laboratory Medicine Catalogue,
digital techniques in histopathology and genetics will be
essential to achieve quality improvement.
We hope that this report will highlight the range of
excellent initiatives already underway in NHS Pathology
which point to the opportunities for digital innovations to
improve care and make better use of resources.
Dr Ian Barnes PhD FRCPath
Chair, Pathology Quality Assurance Review Board,
NHS England
Digital First / Pathology / 3
Executive summary
Around 95% of clinical pathways rely
on patients having access to efficient,
timely and cost effective pathology
services. Pathology touches all of our
lives,
Digital from
First – before
PATHOLOGYwe are born to, in
many cases, after we die.
Around 95% of clinical pathways rely on patients having access to efficient, timely and cost-effective pathology services. Pathology
has embraced digital technology to enable it to deliver these objectives. There are many innovative digital enhancements that will
have a significant impact across health delivery. The challenge for commissioners is to understand how pathology benefits service
delivery, and then to drive change and enable digital innovation in pathology to help realise wider strategic objectives. digital.innovation.nhs.uk
digital.innovation.nhs.uk
Through our primary care and other clinicians and Pathology has embraced digital technology to enable it
healthcare professionals, we rely on pathology to help:
SCREENING
>50%
to deliverofthese services.
biochemical Because
tests related pathology
to chronic supports
disease management
UNG PEOPLE
healthcare throughout care pathways, there are
70% of all diagnoses made in the NHS
WBORN
PATHOLOGY
• Diagnose our illnesses
itions
Pathology involved in
STAYING HEALTHY
mental health
PLanned care
many innovative digital enhancements that will have a
ACUTE CARE
MATERNITY AND NE
end of life
long term cond
800M tests performed annually
CHILDREN AND YO
DIAGNOSTICS
•S
creen us for congenital diseases, cancer and Nearly
significant impact across health service delivery, helping
other conditions
MONITORING
300k patients
clinitians delivery
haveevidence
a test each based care and helping
working day
•M
onitor the progress of disease and manage patients manage their own conditions.
50M electronic results reports sent by labs to GPs annually
our therapies
PATHOLOGY SERVICES SUPPORT EVERY LAYER OF NHS CARE PROVISION
QUALITY OUTCOMES
PATHOLOGY DIGITAL SERVICE INNOVATION
PATIENT-CENTREDNESS
SERVICES INNOVATION TRANSFORMATION EFFICIENCY
PATIENT SAFETY
The ability of digital to enable effective pathology service delivery must start with understanding user needs - patients,
clinicians, commissioners. Digital is only an enabler
The ability of digital to enable effective pathology service We have to ensure that services are accessible to all
delivery
Examplesmust
of howstart with
existing understanding
digital improvements canuser
help toneeds of services
transform healthcare those who need them, and we are living in a digital
– patients, clinicians and commissioners. We need world where people now
NEED
expect to SOLUTION
be able toBENEFITS
access
SYSTEM
to appreciate that digital is only an enabler – the first information and 1services in a way and at a time that
Patients need access to
test results in a timely
way through a channel
Patient access to test
results by SMS
Preferred by clients
Quicker – earlier
opportunity to
of their choice
step is to understand how services can be designed is convenient for them, and the benefits of delivering
change behaviour
service Individuals need to be The Renal Patient Patients feel in control
2
to better serve patients while also delivering safer and through digital channels can be huge.
empowered to take control View project
Empowering
of their own health
more efficient care. Digital, by its nature, can open
Clinicians need to ensure that Empath intelligent Patient-centred
3 systems are in place to allow management of
Saves face-to-face
inician cl
results to be delivered in a way test results
for when needed
This report contains a number of great examples from
that is appropriate to the
BE
up new possibilities and can inspire different ways of
patient and the message
S
se ess managemen
iduali d result
FIT
NE
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FIT
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BE
S
SOLUTION SOLUTION
In
P
t
s
Specialists need as much Digital colonoscopy Richer information
thinking C–hain oitf cusshould never be applied
Empath
for its own sake,
intelligent
management of
Clinical
dashboards across the NHS 4in England where digital thinking has
contextual information as
possible to analyse samples
for interpretation
Better quality
patient ssing boundries
tody – A&E and interpret test results
decision-making
Cro
test results
S SOLUTION
but we should be at a stage where digital is not merely
BENEFIT
3 ITS 7 helped to deliver real service enhancements.
SOLUTION BENEFIT
S
BE
RFID sample F Virtual Clinicians and multi-disciplinary CK Ideas Renal Relevant information
NE
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BE
5
FIT
trackin pathology teams need specialist support Care Programme available to team
S
– Manchester – Leeds to enable effective clinical
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as an add-on option.
BENEFIT decision making
ess to results
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empowerm BENEFI decision-making
S
ent
Acc ati en
8 SOLUTION SOLUTION
11
P
t
Clinicians and multi-disciplinary MATE MDT tool Relevant information
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BENEFITS to test results Patient
View project
BENEFITS 6 teams need specialist support
to enable effective clinical
available to team
Specialist input to
by SMS
IN OF CUSTODY ssing boundries
decision making
CHA
decision-making
Cro
SOLUTION 1 2 BENEFITS SOLUTION
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7 understand process flows and
status of tests to enable better
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ext for analys cialist support
S
BENEFITS EFIT EFIT BENEFIT Patients diagnosed and
PPID – Oxford
ont Spe
S
i BEN S service management
treated quicker
SOLUTION SOLUTION
C
s
9 10
BENEFITS
Digital Labs need to receive samples RFID sample tracking Better management of
MATE MDT tool
colonoscopy
8 that are correctly identified and – Manchester critical samples
4 / Digital First / Pathology Spe
cialist support linked to the patient and clinician
Auditable chain of custody
4 SOLUTION 6
S BEN
IT
BE NEF EFIT
S
CK Ideas Renal Labs need to receive samples Electronic requesting Better management of
Care Programme 9 that are correctly identified and
linked to the patient and clinician
and reporting with
PPID – Oxford
critical samples
Safer and quicker
turnaround for patients
5
Pathologists needs to work NPEX Effective links between
BENEFITS
10 effectively across disciplinary,
organisational and
labs and specialist services
Quick and accurate
800M tests performed annually Nearly
ment
MATERNIT
en
CHILDREN A
STAYI
AC
long te
PLa
PAT
MONITORING
300k patients have a test each working day
50M electronic results reports sent by labs to GPs annually
PATHOLOGY SERVICES SUPPORT EVERY LAYER OF NHS CARE PROVISION
QUALITY OUTCOMES
PATHOLOGY DIGITAL SERVICE INNOVATION
PATIENT-CENTREDNESS
SERVICES INNOVATION TRANSFORMATION EFFICIENCY
PATIENT SAFETY
Digital First – PATHOLOGY The ability of digital to enable effective pathology service delivery must start with understanding user needs - patien
Around 95% of clinical pathways rely on patients having access to efficient, timely and cost-effective pathology services. Pathology
clinicians, commissioners. Digital is only an enabler
has embraced digital technology to enable it to deliver these objectives. There are many innovative digital enhancements that will
have a significant impact across health delivery. The challenge for commissioners is to understand how pathology benefits service
delivery, and then to drive change and enable digital innovation in pathology to help realise wider strategic objectives. digital.innovation.nhs.uk
Examples of how existing digital improvements can help to transform healthcare services
digital.innovation.nhs.uk
NEED SOLUTION BENEFITS
SYSTEM Patients need access to Patient access to test Preferred by client
SCREENING
>50% of biochemical tests related to chronic disease management
1 test results in a timely
way through a channel
of their choice
results by SMS
Quicker – earlier
opportunity to
change behaviour
UNG PEOPLE
servicePathology involved in 70% of all diagnoses made in the NHS
WBORN
PATHOLOGY
itions
Individuals need to be The Renal Patient Patients feel in co
STAYING HEALTHY
mental health
2 empowered to take control View project
PLanned care
Empowering
ACUTE CARE
MATERNITY AND NE
end of life
of their own health
long term cond
Nearly 800M tests performed annually
CHILDREN AND YO
DIAGNOSTICS
Clinicians need to ensure that Empath intelligent Patient-centred
3 systems are in place to allow management of
Saves face-to-face
clinician
results to be delivered in a way test results
300k
for when needed
that is appropriate to the
patients have a test each working day
BE
patient and the message
S
se ess managemen
iduali d result
FIT
NE
NE
FIT
div roc
BE
S
MONITORING SOLUTION SOLUTION
In
P
t
s
50M electronic results reports sent by labs to GPs annually
Specialists need as much Digital colonoscopy Richer information
4 Empath
intelligent Clinical
dashboards
contextual information as
possible to analyse samples
for interpretation
Better quality
management of
patient in of custody ssing boundries
– A&E and interpret test results
Cha test results
Cro
decision-making
PATHOLOGY SERVICES SUPPORT EVERY LAYER OF NHS CARE PROVISION 5 SOLUTION SOLUTION
BENEFI TS
TS S BENEFI
FIT
BE
RFID sample Virtual Clinicians and multi-disciplinary CK Ideas Renal Relevant informat
NE
NE
BE
FIT
trackin pathology teams need specialist support Care Programme available to team
S
– Manchester – Leeds to enable effective clinical
BENEFI Specialist input to
decision making
ess to results
TS
empowerm BENEFI decision-making
ent
TS
Acc ati en
QUALITY OUTCOMES
PATHOLOGY DIGITAL SOLUTION
SERVICE SOLUTION
P
t
Patient access The Renal INNOVATION Clinicians and multi-disciplinary MATE MDT tool Relevant informat
BENEFITS to test results Patient BENEFITS 6
PATIENT-CENTREDNESS
teams need specialist support
to enable effective clinical
available to team
SERVICES INNOVATION TRANSFORMATION
by SMS View project Specialist input to
IN OF CUSTODY ssing boundries
decision making
CHA Cro EFFICIENCY decision-making
SOLUTION S BENEFIT SOLUTION PATIENT SAFETY
Electronic BENEFIT S Clinicians and labs need to Clinical dashboards Better scheduling
requesting and
reporting with BEN
NPEX
7 understand process flows and
status of tests to enable better
– A&E between A&E and
ext for analys cialist support
S
BENEFIT
S EFIT EFIT BENEFIT Patients diagnosed
The ability of digital to enable effective service delivery must PPID – Oxford
ont
pathology start
Spe with understanding user needs - patients,
S
i BEN S service management
treated quicker
SOLUTION SOLUTION
C
s
clinicians, commissioners. Digital is only an enabler
BENEFITS
Digital Labs need to receive samples RFID sample tracking Better manageme
MATE MDT tool
colonoscopy
cialist support
8 that are correctly identified and
linked to the patient and clinician
– Manchester critical samples
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Examples of how existing digital improvementsBENEFcan
ITS help to transform healthcare
SOLUTION services BEN
EFIT
S
CK Ideas Renal Labs need to receive samples Electronic requesting Better manageme
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NEED SOLUTION
9BENEFITS that are correctly identified and
linked to the patient and clinician
and reporting with
PPID – Oxford
critical samples
SYSTEM Patients need access to Patient access to test Preferred by clients
Safer and quicker
turnaround for pa
1 test results in a timely
way through a channel
results by SMS
Quicker – earlier
opportunity to
of their choice Pathologists needs to work NPEX Effective links bet
BENEFITS
change behaviour
10 effectively across disciplinary,
organisational and
labs and specialist
Quick and accurat
service Individuals need to be The Renal Patient Patients feel geographical
in control boundaries
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2 empowered to take control
of their own health
View project
Empowering
Pathologists needs to work Virtual pathology Quicker and safer
3
Clinicians need to ensure that
systems are in place to allow
Empath intelligent
management of
11 effectively across disciplinary,
Patient-centred
organisational and
Saves face-to-face
– Leeds
Easy to get a spec
second opinion
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results to be delivered in a way test results geographical boundaries
for when needed
that is appropriate to the
BE
patient and the message
S
se ess managemen
iduali d result
FIT
NE
NE
FIT
div roc
BE
S
SOLUTION SOLUTION
In
P
t
s
Specialists need as much Digital colonoscopy Richer information
Empath
4 contextual information as for interpretation
What commissioners should ask intelligent Clinical
possible to analyse samples
Benefits delivered include: These projects have improved how things work within
management of dashboards Better quality
patient
in of custody ssing boundries
– A&E and interpret test results
Cha test results
Cro
decision-making
BENEFIT
S SOLUTION 3 S 7 SOLUTION BENEFIT
S
pathology but, more importantly have delivered benefits
FIT
BE
RFID sample Virtual Clinicians and multi-disciplinary CK Ideas Renal Relevant information
NE
NE
BE
5
FIT
USING tTHE
o resul TECHNOLOGY INTEGRATION EFFECTIVE COMMISSIONING
teams need specialist support Care Programme available to team
SERVICE
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S
• People feeling more iness control of their health empowthrough
– Manchester – Leeds to enable effective clinical
BENEFIT Specialist input to
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erm BENEFI decision-making
S
ent
Acc ts
at the interface between
workingpathology and thethe services
Are itour commissioning and procurement models
ati en
8 OLUTION SOLUTION
11
P
t
better access to test
Are
results
to deliver
services using
the best service they can?
BENEFITS
ourS pathology
Patient access
digital
The Renal
Patient
technologies
BENEFITS
Are our clinicians
6
with and supporting
teams need specialist support
integration of pathology services
Clinicians and multi-disciplinary
available to team
to enhance patient care?
MATE MDT tool
supporting innovation in pathology services?
Relevant information
supports.
to test results to enable effective clinical
by SMS View project Specialist input to
IN OF CUSTODY ssing boundries
decision making
CHA
decision-making
Cro
• Multi-disciplinary teams1 having timely information
2
and
S OLUTION SOLUTION
BENEFITS
Electronic BENEFITS Clinicians and labs need to Clinical dashboards Better scheduling
requesting and
reporting with BEN
NPEX
7 understand process flows and
status of tests to enable better
– A&E between A&E and lab
ext for analys cialist support
S
specialist9 advice toSOenable better treatment planning The challenge now is for commissioners and providers
BENEFITS EFIT EFIT BENEFIT Patients diagnosed and
PPID – Oxford
ont Spe
S
i BEN S service management
treated quicker
LUTION SOLUTION
C
s
10
BENEFITS
Digital
to understand how
8 pathology benefits service delivery,
MATE MDT tool Labs need to receive samples RFID sample tracking Better management of
colonoscopy that are correctly identified and – Manchester critical samples
• Better workflows between wards and labs to improve
rt cialist suppo linked to the patient and clinician
Spe Auditable chain of custody
4 SOLUTION 6
S BEN
and then drive change and enable digital innovation in
EFIT EFIT
BEN S
Labs need to receive samples Electronic requesting Better management of
turnaround times and improve patient care
CK Ideas Renal
Care Programme 9 that are correctly identified and
linked to the patient and clinician
and reporting with
PPID – Oxford
critical samples
Safer and quicker
pathology to help realise wider, longer-term strategic
turnaround for patients
5
• Better identification and management of samples to
Pathologists needs to work NPEX Effective links between
objectives.
BENEFITS
10 effectively across disciplinary,
organisational and
labs and specialist services
Quick and accurate
geographical boundaries
sharing of data and images
enhance patient convenience and safety and reduce Pathologists needs to work Virtual pathology Quicker and safer diagnosis
11 effectively across disciplinary, – Leeds
the cost impact of re-testing
Easy to get a specialist
organisational and
second opinion
geographical boundaries
What commissioners should ask
USING THE TECHNOLOGY SERVICE INTEGRATION EFFECTIVE COMMISSIONING
Are our pathology services using digital technologies Are our clinicians working with and supporting the Are our commissioning and procurement models
to deliver the best service they can? integration of pathology services to enhance patient care? supporting innovation in pathology services?
Digital First / Pathology / 5
>50%
of biochemical
tests are related to
chronic disease
management1
Pathology
is involved in
70%
of all diagnoses
made in the NHS2
Nearly
800
million
tests performed annually
(14 for each person in
England and Wales)3
300k
patients
have a test each
working day4
6 / Digital First / Pathology
50
million
electronic results
reports sent by labs
to GPs annually4
500
million
biochemistry and 130
million haematology tests
carried out per year5
Digital First / Pathology / 7
Context
The NHS is in a period of rapid change – not only
are the demands on it growing and changing, but
widescale transformation is in progress, making
sure we deliver the best outcomes for patients.
Review of the quality and value of services helps
drive the culture of continuous improvement to
serve the needs of the future.
Laboratory medicine is undergoing its own • advances in disciplines such as genomics and
transformation, both as a result of scientific and metabolomics that will increase demand on pathology
technological advances, and in response to the need to for predictive and preventative investigations
meet growing demands.
•the potential of Summary Care Records to support
identification of trends and warning signs in individuals’
In his review of pathology services in England2, Lord
health events.
Carter of Coles spelled out the way in which the level of
demand on pathology has been accelerating, including:
Pathology services are implementing the
recommendations of the Carter report, and in particular
• an ageing population with an associated higher rate of
finding ways to consolidate services to build physical and
chronic disease
virtual structures that can respond to these demands.
• the shift towards personalised medicine
8 / Digital First / PathologyThe role of pathology
Delivering real improvements for patients
means that clinicians, service managers and
commissioners must identify the opportunities
for improvement in care pathways. Key to this is
understanding the roles and interplay between
different clinical specialties and services, and how
to maximise the value of those elements to the
whole and remove or redesign parts of the system
that do not add value.
Pathology is involved in 70% of all diagnoses made in the Pathology’s relevance to delivering better outcomes
NHS . But that figure underplays the role that pathology
2
is due to its role throughout pathways, and not just at
plays in screening and monitoring, and particularly in the point of diagnosis – 95% of clinical pathways rely
management of chronic conditions. And Pathology is not on patients having access to efficient, timely and cost-
just a back-office function – it provides direct patient care effective pathology services6. Innovations within pathology
in many specialist situations including clinics, infection have a significant impact across health delivery.
control and as part of multi-disciplinary teams (MDTs).
Pathology touches us MIDDLE Y
EARS
throughout our lives Ongoing
Pre-op group
and screen test cholesterol
monitoring
Cervical cancer Bowel cancer
screening screening
ULT
Blood test Biopsy
AD
in A&E investigation
NG
YOU
Monitoring
Diagnostic effect of therapy
investigation and its
by GP complications
Chlamydia Prostate
screening cancer test
SENIOR
Disease
staging/
Anaemia test
progression/
remission
Newborn blood Dementia
CHILD
spot screening screening
Ante-natal Post-mortem
screening investigation
END OF
LIF
E
Digital First / Pathology / 9Pathology services impact at
all stages of care pathways
SCREENING
UNG PEOPLE
EWBORN
PATHOLOGY
itions
Y
mental health
STAYING HEALTH
PLanned care
ACUTE CARE
end of life
long term cond
MATERNITY AND N
CHILDREN AND YO
DIAGNOSTICS
MONITORING
A key issue in building business cases for change within In the case of infectious diseases, and particularly where
pathology is that in many cases it is not pathology – as carrier behavior has a significant impact on their spread,
defined as a discrete service – that will see savings or for example STIs, there is evidence that shortening the
even improved outcomes in itself. Hence investment turnaround time from test to treatment is not only better
needs to be seen in the round and not just in silos. for the patient but for the population as a whole.
Improvements are often at the interface with users or
through achieving greater efficiencies and effectiveness The introduction of liquid-based cytology testing in
in the services of clinical users. In the short term, this cervical screening was another example of a great
could be through more accurate test requesting and success, where a modest investment in pathology
reporting, but in the long term this will be by tapping transformed the pathway. It dramatically saved cost and
into the enormous potential for streamlined pathways, improved sample quality and the service provided to
personalised healthcare and preventive medicine. patients.
In its recent review of blood sciences6, NHS Innovation The challenge for pathology is to find other ways
cited a number of case studies where simple process to promote its wider role in care pathways so that
improvements around the collection, processing and investment made in the lab or at the lab interface is
reporting of blood samples in a hospital setting made a linked to benefits manifested elsewhere. The challenge
significant impact on other areas, such as patient safety for commissioners is to understand how pathology
in the operating theatre (by improving the availability of benefits service delivery, and to drive change and enable
Group and Screen results prior to surgery) and to length digital innovation in pathology to help realise better value
of stay. Conversely, in one “before” case the misaligned healthcare and better outcomes.
timing of sample collection and analysis in relation to ward
rounds had turned what should have been a 38 hour stay
in hospital into an eight-day stay for one patient.
10 / Digital First / PathologyThe digital dimension
In the context of an evolving NHS, the central
role of information, and digital technology as an
enabler to sharing information and innovation
in care, is receiving serious focus. There are
particularly exciting opportunities as the emphasis
shifts from the treatment of illness to the 90%
of all interactions in
maintenance of good health. healthcare are face-to-face
– a 1% reduction
could save up to
The NHS IT strategy focuses on the power of information
7
and need, that supports the
£200m 9
to deliver the ambition for patient-centred healthcare. quality and value agenda and
Almost 22 million people now have Summary Care results in better patient
Records (Dec 2012) with rollout continuing, and these are outcomes.
already delivering benefits in emergency care settings . 8
The move to patient online access to GP records – Digital First is focussed on harnessing the potential of
including test results – by 2015, and eventually to fully digital channels to enable patients and healthcare
integrated electronic health and social care records, will be professionals to interact in different ways, reducing
transformative in the relationship between health face-to-face contact where this is not considered by
professionals and patients, and between patients and their clinician or patient to be necessary, and providing access
health and wellbeing. that is more appropriate and convenient to people’s
lifestyles and needs. In the context of support services,
Online services such as NHS Direct and NHS Choices – these principles also apply to contact between healthcare
which will soon evolve into a single health portal – show professionals and the ways in which services are
there is an appetite; the challenge for health services is to managed and delivered.
use digital to deliver services in a way that people want
Last year, NHS Direct handled over 10 million online Every month, there are over 25 million website visits
assessment episodes, for which over 14% were to nearly 500 online health and wellbeing sites by UK
carried out on mobile devices citizens, with NHS Choices accounting for over half of
all traffic and WebMD handling nearly two million visits
10.6 Million 25 Million
Online assessments website visits
= 500
Web
started Visits
14%
Assessments via
online health and
wellbeing sites
mobile devices
2012 figures
Digital
Digital First
First // Pathology
Pathology // XX
11Pathology has a long history of
embracing technology
As a scientific clinical service, pathology has a long
history of embracing technology to support laboratory
operations. It has also been at the forefront of 50M
electronic reports
informatics, in particular information standardisation and
management, and has a mature informatics infrastructure. sent from labs to
GPs a year4
At a strategic level, the new National Laboratory Medicine
Catalogue is leading the way in the NHS by developing
information standards that will have a positive impact on
patient safety, system interoperability and the value of
data to the health system as a whole.
Many areas of pathology are highly automated, and most Each of these examples has brought benefits to
laboratories manage their samples and workflow with the practice of pathology itself and, probably more
some form of automatic identification and data capture importantly, adds value in terms of efficiency, patient
(AIDC) – the majority using barcode systems to label and safety and quality of care, which go beyond the
identify samples within the lab. Digital pathology is also boundaries of the laboratory.
gaining ground in specialist areas such as histopathology,
There is however, still a huge amount of untapped
as it allows for transmittable images and voice recognition
potential, and while the production side of pathology
to capture complex narratives.
can be made more efficient and responsive through
Most labs also use some sort of laboratory information innovation, the true value of pathology will only be
management system (LIMS) to manage their data, and released if it is viewed not as a production unit but as
order communications systems enabling clinicians in a customer-focussed service11, where more significant
primary and secondary care settings to make electronic gains can be made through exploitation of the
requests for tests are now in widespread use. Test result digital opportunities in the clinical value chain. Digital
reports are sent electronically to primary care clinicians technologies will enable linkages and communication to
from all NHS labs via the NHS Spine using Pathology happen more easily, between pathology professionals
Messaging Implementation Project messaging (PMIP) and across specialism and geographical boundaries.
– totalling 50 million electronic reports a year (2012)4 .
These transmissions enter results into the GP-held patient
record automatically.
12 / Digital First / PathologyDigital quick fixes healthcare settings and within appropriate data security
parameters. They are already delivering proven benefits
Innovation is not just about new technologies, across the NHS, so provide quick building blocks for
but also about new ways of applying existing service improvement and further innovation.
technologies. NHS organisations already have
access to a range of digital tools and channels that In addition, application of technologies for remote support
can enable smarter communication with patients, and healthcare are becoming more widespread in the
fellow professionals and other stakeholders and NHS, and in many cases impact on and are impacted by,
the development of faster, safer, better ways for developments in laboratory medicine.
managing processes and information that impact
on patient care and experience. Telecare – remote monitoring of emergencies and lifestyle
changes to manage the risks of independent living
Voice
Digital dictation recognition Telehealth – remote monitoring of specific health
indicators such as INR (Warfarin monitoring), blood
pressure, blood oxygen levels or weight. Solutions vary
Automatic ID
Digital clinical from simple SMS links to more complex technologies
and data capture
correspondence
(AIDC)
Telemedicine – remote consultation eg. between patients
and consultants or between GPs and specialists. Can
Voice Over be real-time or via data (eg images) captured and sent
Mobile working Internet
for expert second opinion, such as very high resolution
Protocol (VOIP)
histopathology sample images for cancer diagnosis.
QIPP Digital Technology has produced a useful guide to
Online meeting
Secure SMS enabling technologies:
services
Many of these are available free or at competitive prices, Digital technology essentials guide – go to:
with pay-as-you-go models rather than those requiring http://www.networks.nhs.uk/nhs-networks/
up-front capital investment. There are applications that qippdigital-technology-and-vision/documents/
have been developed or adapted specifically for use in QIPP_DT_Technology_Essentials_Guide.pdf
Using SMS to report results
SMS is low cost and widely used, with 92% of Since 2004 the Isle of White NHS Trust has been using SMS
people in the UK now owning a mobile phone and 129 to inform patients of negative results from the Sexual Health
billion text messages sent within the UK in 2010. There Service. In 2006 this was extended to include appointment
is growing evidence that users see SMS as a secure reminders. The initiative has reduced missed apointments
direct communication channel and less likely to from 22.5% to 14.1%, has reduced clinic appointments by
compromise confidentiality than letters or landline more than 3,000 and avoided 4,000 letters each year. The
phone calls. cost efficiencies add up to more than £350k12.
Digital First / Pathology / 13Opportunities to exploit innovation
If all laboratories and pathology services
implemented those digital services already used by
some labs, and all used them to their full potential,
it would result in benefits without requiring any
further innovation.
For example, laboratory information systems enable data Despite the fact that PMIP messages can feed results
mining and analysis, but to date haven’t been widely directly into GP systems, there is potential for further
used for this purpose. The potential of this data lies improvements to make these links more effective and to
in pathology’s role in the delivery of care along patient really use the data that is available to enhance patient test
pathways, and in identifying trends and links between management.
treatments and outcomes.
In other cases, better processes outside the lab will have
Although improving laboratory systems and processes an impact on the quality of service delivery from the lab. A
through digital technology is good in itself, it could digitally enabled system for managing information within
be much more beneficial if the full potential of digital a laboratory relies on the quality of data coming in, so if
connectivity was harnessed. Order communications a sample is wrongly labeled, no amount of bar coding or
systems for instance have created a paperless, other asset management systems within the lab is going
structured transaction between clinicians and labs and to fix that error. Given the potential impact of poor sample
are already helping to improve the quality of test requests management in delaying diagnosis and treatment for
and reducing errors. Current systems are still fairly the patient, and the costs and inconvenience of repeat
rudimentary, and not properly integrated with primary testing, there is a clear incentive for the clinical services
care or hospital systems. Although they can capture collecting samples to make improvements in their own
some information from the clinical systems, such as sample management. You can read later in this report just
the patient’s NHS number, the value of fully integrated how using digital technologies at the point of testing are
systems connecting information across an EPR would be helping to resolve this.
immense, for example enabling features like the creation
of automatic queries when a test is ordered that is
impacted by a patient’s medication.
14 / Digital First / PathologyThese and other issues occur at the interface between This is not just down to the professionals working
pathology and other parts of the care pathway, and it is within health. Increasingly, it will be about driving market
these areas that pathology must now seek to address, innovation through commissioning specifications and
by supporting the spread of innovation to all users choices. As industry also takes its agenda on board, the
and providers. Keeping up the momentum and, most suppliers of GP systems are already starting to look at
importantly, connecting across service boundaries, will how order comms can be integrated into their products.
maximise this potential and ensure that the opportunities
provided by technology in general, and digital technology
in particular, are not missed.
“Pathology is an information business.
Pathologists provide useful answers
to good questions.” 10
Digital First / Pathology / 15Making procurement The procurement model has been developed to
encourage a dynamic and responsive marketplace that
quicker and simpler
supports emerging suppliers. Many of the services are
The NHS IT Strategy signalled a move away from
7
offered on a pay-as-you-go basis without big up-front
centralised IT procurement towards more local capital costs, which can support a totally different
responsibility. This doesn’t mean the end of national business model for digital innovation.
infrastructure programmes (eg. the Spine), but it
does open the way for more locally responsive Although in its infancy (the G-Cloud framework and
solutions and innovation. CloudStore were launched in February 2012) it lists over
3,500 services.
At the same time, initiatives such as G-Cloud are helping
to support a more flexible procurement approach. All this is good news for pathology services looking for
G-Cloud is a cross-government programme focused agile, innovative approaches to service needs that can
making public sector IT procurement easier and deliver benefits faster, and cheaper.
encouraging more SME providers to enter the market.
More information:
The G-Cloud CloudStore is an online catalogue of G-Cloud:
products and services, which have been procured under http://gcloud.civilservice.gov.uk
the OJEU process and can therefore be bought ‘off CloudStore:
the shelf’ by individual organisations without having to http://gcloud.civilservice.gov.uk/cloudstore
undergo a lengthy procurement processes.
Buyer beware
There are many considerations when commissioning A similar problem arose when radiology services were
services, but never assume all providers have the same outsourced some years ago and x-rays were returned in
digital credentials. There are examples of tenders for non-standard formats.
pathology tests that have failed to specify that results
should be returned in electronic format, with the result that Commissioners should ensure that they understand how
the commissioning laboratory receiving results from an the inputs into pathology services affect the quality and
outsourced service has to input manually all of the efficiency, as much as the service itself.
paper-based results on to its LIMS, adding cost and delay.
16 / Digital First / PathologyUnlocking the potential of data
The power of information in helping us to
understand issues and trends and to improve
services, will be unlocked by creating a digital
ecosystem. Data will be collected, stored and
transmitted in a way that allows interoperability
between systems and clear interpretation at the
point of use – whether that be in a patient care
setting or for public health research.
Transferable data is a pre-requisite of joining up digital Pathology has been at the forefront of developing and
information systems and processes, and that means we adopting data standards – SNOMED was created
all have to be speaking the same language. The challenge out of over 40 years work by the College of American
is not only to physically transfer data, but to ensure that Pathologists as well as international collaboration. It is
its meaning is clear and its context is preserved. the most comprehensive international clinical terminology
available, now adopted across all clinical areas, not just
The NHS has adopted three standards to ensure that IT pathology.
systems can communicate with each other, to support
and enable better end-to-end care of patients and The creation of the NHS National Laboratory Medicine
efficient and effective back end processes: Catalogue (NLMC) is building on these standards. It is
the UK’s first comprehensive catalogue of test requests,
• SNOMED-CT* – for the unambiguous identification
and provides a clinical content information standard using
of clinical concepts such as diseases, findings and
SNOMED-CT coding terminology and additional content
procedures. This includes pathology sub-sets
on appropriate tests and techniques, quality assured and
•H
L7 – for the exchange of messages between systems validated for use across the NHS.
from different manufacturers. This includes a set of
pathology-specific messages
•N
HS number – for the unambiguous identification
40%
of patients
Used together, these standards will ensure that all of tests ordered
systems and services are able to link and share data are not necessary13
clearly and safely.
* Systematized Nomenclature of Medicine Clinical Terms
Digital First / Pathology / 17National Laboratory Medicine Catalogue
NLMC
UESTS
DIRECT
T REQ
REPO
TES
RTS
GLE
Test name
Analyse Specimen
Pre-analytical
SIN
Measurement type
Requirements
Analytical
Sample type
Technique
Unit of Measure DER Morphology
IV E D Topography
ILES
Data combination
Indicator REPO PROF
Sample preconditions
RTS Collection method
Calculations Agreed
Special combination
Interpretations of tests
The catalogue embodies the principle of enabling effective NLMC is a joint initiative between the Department of
and safe communication through the use of unambiguous Health, NHS England , HSCIC and the Royal College of
standard naming conventions and, by providing decision Pathologists, with clinical input from across the NHS and
support and improving test evaluation, it will help industry. It is designed to be a living, web-based resource
clinicians find and order the right test and reduce the and is being developed using open-source principles
number of inappropriate test requests. Conceptually with online, real-time editing, moderation, validation and
equivalent to the British National Formulary (BNF), NLMC professional sign-off.
has the potential not only to list diagnostic tests, but to
be used to support service delivery, regulation, innovation
and research.
Although the existing catalogue of pathology reports, the
Pathology Bounded Code List (PBCL), enables electronic
data transfer between clinical laboratories and other
clinical systems via Pathology Messaging Implementation
Project (PMIP) messages, its limitations are becoming
increasingly apparent as data needs to be shared more
widely between multi-disciplinary teams, clinical networks
and disease registers. The inception of the combined
patient record will focus this need still further.
18 / Digital First / PathologyOpen data standard for pathology
NLMC will provide the standardisation required to make As experienced in industry and other public sector
pathology data open to all those who want to use it – not organisations, opening up access to data through
just clinicians and patients, but others including screening standardisation should also lead to innovation and
programmes, disease registries and service commissioners. novel applications – data can be combined and used
in new ways to create new information-based services
Standardisation will make it easier to use tools like the that respond to user needs. Popular examples outside
Atlas of Variation to interpret differences in investigation medicine include crime data mapping and real time,
policies across the country, as it will be clear that like- location-sensitive transport information about tube or
for-like comparison is being made. It will also make trend bus services or bike share availability.
analysis more accurate and meaningful.
The catalogue is being built in phases, and the first The NLMC team is encouraging services to implement
version is now available as a ‘technology preview’ the catalogue on a trial basis, to evaluate its usefulness
release. As a starting point, this concentrates on basic and safety, and to suggest improvements. This feedback
standardised content relating to pathology single test will be incorporated into plans for further developments,
requests on seven areas: and may lead to NLMC eventually replacing PBCL.
• Clinical biochemistry
The benefits of the NLMC will grow over time, as more
• Haematology tests and disciplines are added to the catalogue, and as
more pathology services implement it.
• Blood transfusion
• Immunology More information:
• Histopathology National Laboratory Medicine Catalogue:
http://www.laboratorymedicine.nhs.uk/
• Cytology
• Virology HSCIC – NLMC:
http://www.hscic.gov.uk/
The focus is on implementation into new systems,
as it is recognised that many existing systems have http://systems.hscic.gov.uk/pathology/projects/
limitations that would prevent compliance with NLMC nlmc/nlmcrelease/keymessages
implementation rules. Having an open and ready-made
catalogue of pathology tests validated for use in the NHS
will lead to significantly shorter implementation times for
new electronic order communication systems.
Digital First / Pathology / 1920 / Digital First / Pathology
Examples of digital
innovation in pathology
There are many examples
around the country of
pathology using digital
innovations to improve
service delivery, patient
safety and communication,
among other things. The
following is just
a snapshot of the range of
initiatives that are already
delivering improvements that
help patient care
Digital First / Pathology / 21Transformative
infrastructure
The National Pathology Exchange (NPEx)
The full value of digital technology comes in connecting people and
services – efficiencies can be limited where manual processes are
needed as inputs and outputs of automated systems. The National
Pathology Exchange (NPEx) is a national data exchange service that
provides the missing link in lab-to-lab communications.
Insights
NPEx provides a solution for these issues in lab-to-
lab communications, by establishing a direct interface
between laboratory LIMS systems and a national hub,
creating a streamlined, paperless process.
The digital service uses a Microsoft BizTalk messaging
engine, which converts local codes to HL7 messaging
and NLMC SNOMED coding standards, and enables
interoperability between LIMS such as iSoft and CliniSys.
Messages go via the NPEx exchange hub, which is
located in a secure NHS data centre.
NPEx was inspired by a DH think-tank in 2001 and created
by X-Lab Systems based at the University of Leeds. It
Complexity was first installed across the nine labs of the Greater
Moderate Manchester Pathology Network in 2009. The service is
managed by The Health Informatics Service (THIS), hosted
Background by Calderdale and Huddersfield Foundation Trust and is
Though the majority of core laboratory services are highly the largest informatics shared service in the UK. Around 30
automated and computerised, the referral of samples to NHS laboratories are using NPEx to digitise their lab-to-lab
other centres is still paper driven. communications, and by August 2014, 25% of the NHS
labs in England expect to be connected.
It is estimated that around six million pieces of paper are
sent between NHS laboratories and manually input into
computer systems every year (2001 figures), using an
estimated 300 resource years and introducing the risk of
errors and delay in patients receiving their results14.
The volume of lab-to-lab communications will continue
to grow with the consolidation of specialist services, the
rapid growth in point of care testing and the opening up
of the marketplace for laboratory services.
22 / Digital First / PathologyAn additional benefit of NPEx is that it allows the progress • At least one day faster service as results received
and physical location of tests and results to be tracked. electronically and not by post
It can also provide pathology managers with a view of
• Reduced opportunity for errors introduced during
tests offered by other labs, how much they charge and
data entry
turnaround times. Opening up this information about
the marketplace should help to drive improved service • Auditable sample trail – bar-coding used from
performance because it will lead to more intelligent end-to-end
pathology commissioning, for example outsourcing tests • Reduces ad-hoc enquiries as electronic status checking
that can be done more cheaply or faster elsewhere. and monitoring
As more labs in more regions get linked up to the system, • View of market intelligence supports better
the value of this market transparency will increase. In commissioning decisions
addition, by providing interoperability between different • Could help break down the organisational and
LIMS, NPEx provides a way of joining up services geographical barriers to collaboration
regardless of whether they are using the same LIMS.
These benefits should enable procurement and Next steps
collaboration across network and geographical boundaries, Roll-out so far has tended to be regional – it makes sense
reshaping pathology services in ways that go beyond the that with most lab-to-lab work currently mainly within
regionalisation recommended in the Carter report . 2
regions, the greatest benefits will be where those working
together get linked up. The target is to get 50% of labs
This may be some way in the future, but the success in England on NPEx by 2014, and this is expected to
demonstrates the transformative effect that a provide a tipping point that will make it more and more
comparatively straightforward, digitally-enabled business beneficial for all labs to get connected.
change can have.
NPEx interfaces are currently provided by CSC iSOFT,
Likened to the services provided by a telephone CliniSys and Molis, with Roche SwissLab, STARLIMS and
exchange, THIS supplies NPEx using a ‘software-as- Technidata interfaces in development. X-Lab Systems
a-service’ model – participating labs pay a quarterly and THIS are working with other LIMS providers to
subscription fee, which covers network connection and encourage them to develop interfaces too.
support. They must also purchase an NPEx interface
from their LIMS supplier. Costs for this vary according Resources
to supplier, but would not rule NPEx out for most For more information on NPEx and to register for a
laboratories or networks. A free web-based service has free trial, visit: http://www.this.nhs.uk/our-services/
also been developed for low volume users. national-pathology-exchange/
Outcomes You can view a short introductory video to NPEx here:
• Helps deliver faster service to patients and clinicians http://www.npex.nhs.uk/Home/NpexInAction
• Estimated cost savings £1-3 per sample – data entry,
handling, postal and paper
Digital First / Pathology / 23Virtual pathology
Digital pathology promises great improvements in delivering patient care,
including faster test results and ease in seeking a second opinion. With the
use of virtual microscopes this is now becoming possible.
Funded by the Pathological Society of Great Britain and
Ireland, and the National Institute of Health Research
(NIHR) New and Emerging Applications of Technology
(NEAT), a group of researchers at the University
of Leeds (Pathology and Computing) and Leeds
Teaching Hospitals Trust have spent the past four years
developing a virtual microscope to make these benefits
more widely available.
Preparatory work found that it can take 60% longer to
make a diagnosis using digital slides due to the level of
detail they contain and the size of the images – if they
were printed on paper they would be the size of a squash
court, yet most manufacturers only provide slow standard
PC-based desktop software with small screens.
Complexity
Insights
High
The goal of the project has been to create a Virtual Reality
Background microscope that allows for faster diagnoses with the
Digital pathology (the complete digitisation of pathology same accuracy as a conventional microscope, and that
slides) allows for a number of benefits in the delivery histopathologists will feel comfortable using in their day-
of patient care – slides are easier to access, the risk of to-day practice.
slides getting mixed up is radically reduced and patients
can receive specialist review more quickly. The key innovation of the project is to combine expertise
in multiple disciplines (pathology, computer graphics,
Despite these benefits, digital pathology is rarely used ethnography, psychology and medical imaging) to design
outside of research and teaching facilities in the NHS. a digital pathology system which is truly fit for purpose
There are several reasons for the slow uptake of digital for both individual pathologists and the health service.
pathology, including lack of regulatory approval, lack of The system was developed with significant input from
an established cost benefit and pathologists’ reluctance pathologists at Leeds Teaching Hospitals Trust at both
to use the technology. For many of these reasons, an the design and evaluation stages.
underlying cause may be that the currently available digital
pathology software is inefficient and rejected by users.
24 / Digital First / PathologyYou can also read
