ncha proceedings homecare systems workshop...ncha, 105 st peter's st, st albans, hertfordshire...

NCHA ProceedingsHomecare Systems Workshop

NCHA, 105 St Peter's St, St Albans, Hertfordshire AL1 3EJTel 01727 896091 Email [email protected] www.clinicalhomecare.co.uk

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DisclaimerNCHA does not warrant or represent that the material in this document is accurate, complete or current. Nothing contained in this document should be construed as medical commercial legal or other professional advice. Detailed professional advice should be obtained before taking or refraining from any action based on any of the information contained in this document.

NCHA ProceedingsHomecare Systems Workshop

Held on 20th July 2015 in London

ForewordNational Clinical Homecare Association (NCHA) members seek to provide patient centered homecare services that are safe, cost effective and ensure seamless integrated patient care. The NCHA and its members along with wider industry stakeholders have been fully engaged in the DH Homecare Strategy Board (Hackett) workstreams and are committed to the practical implementation of the Royal Pharmaceutical Society (RPS) Professional Standards for Homecare Services.

NCHA was pleased to lead this event to bring together a wide range of key stakeholder to understand and break down the barriers preventing the step change in interoperability of homecare systems that all parties desire. This homecare systems workshop builds on the output based specification and technical specification for Homecare systems from the Hackett IT workstream and other elements of the RPS Homecare Handbook.

This is a key next step in the standardization of processes between NHS and the homecare industry that will underpin efficiency and support a robust homecare market which continues to meet the needs of patients and commissioners as we grow homecare services in partnership with the NHS in response to patient demand.

Alison DavisAlison DavisCEO of the National Clinical Homecare Association


NCHA ProCEEdiNgSHomECArE SySTEmS WorkSHoPHeld on 20th July 2015 in London

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Executive Summary & Abstract:Homecare accounts for up to 25% of the secondary care medicines budget and is relentlessly growing at over 20% year on year. This would rise to 60% if extended to all medicines known to be suitable for homecare. Given the choice, many patients choose to be treated at home rather than in hospital and NHS Five-year-forward view anticipates the further extension of clinical homecare services to treat patients in community settings.

One of the key benefits of the workshop day have been from bringing together people from the different stakeholder groups to develop a common understanding of the importance and challenges of homecare. The lack of interoperability of homecare systems is hampering expansion of homecare services and increasing clinical risk through unplanned growth of services. The urgency of the current situation must be recognised. The priority is to engage senior figures in the various parts of the NHS and other key stakeholders to support these developments. Leadership and prioritisation are the two key things needed – the funding and technical work will follow once the issue has the attention of the decision makers and budget holders. Whilst there are some quick wins, there should be a longer term homecare system development roadmap which addresses all the issues and provides the functionality described in the Homecare Handbook as supplemented in this workshop proceedings report.

The lack of real-time data sharing between healthcare professionals presents a clinical risk; in homecare this risk is compounded as patient data is held by a number of organisations involved in co-ordinating patient care. There is general consensus that a fully paperless and “real time” data exchange system is needed to support homecare services. Whilst some individual Trusts and providers have invested in point-to-point messaging and automation of some manual processes, this has not proved to be a scalable solution. From all stakeholder perspectives the status quo is not an option, a hub solution would meet the needs of all stakeholders and commercialisation is the only way to make it happen in a reasonable timeframe.

Standardisation and automation of current manual administration processes is a key first step. To that end the overall process and detailed invoice and purchase order processes were agreed during the workshop. A paperless system was overwhelmingly preferred by all stakeholders and is achievable except for the requirement to physically transfer the original prescription. There are high hopes that guidance we expect to be issued by Department of Health later in 2015 will clarify the legal status of the homecare prescription and allow the electronic transmission of prescription information between NHS Trusts and homecare providers. Existing data standards are to be used, however, additional standard elements that are specific to homecare should be agreed by NHMC and added to the standards through the appropriate channels.

There is agreement that data ownership and issues of commercial confidentiality will impede the sharing of data needed within a hub solution. The key conclusions from the data workshop were limited

- Recognition of the differentiation between and value of raw data and analytics- The need for resolution that includes all interested groups- The unresolved nature of the issue of providing analytics based on the data that will flow through

the hub should not impede the roll-out of the service provided that no such analytics were made available until the relevant parties had agreed upon its ownership

- Recognition that data issues must be resolved as commercial hub models that have a low unit cost to the NHS will need to generate alternative revenue from data usage

- Observation that no NHS/DH delegates selected the data workshop even though it is a highly emotive subject for many in the NHS

NCHA is committed to supporting a robust and sustainable homecare market in which high quality and cost effective services are provided to NHS commissioners along with excellent services and improves clinical outcomes for patients. NCHA will continue the drive for standardization in homecare processes and will work with the NHMC and RPS to follow up the outputs of this report for the benefit of patients.


NCHA ProCEEdiNgsHomECArE sysTEms WorksHoPHeld on 20th July 2015 in London

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Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Executive Summary & Abstract: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Homecare systems: Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Workshop Overview and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Rationale Methodology, Aims & Outputs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Workshop Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Workshop 1: Purchase order, invoice, payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Workshop 2: Information governance - Rx, and clinical data exchange . . . . . . . . . . . . . . . . . . . . . . . 10

Workshop 3 – Risks and Benefits of the Operating Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Workshop 4 - Data ownership and commercial confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Overall Summary and Conclusions: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Disclaimer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19



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Homecare systems: BackgroundHomecare is currently estimated as accounting for up to 25% of the secondary care medicines budget and is relentlessly growing at over 20% year on year. If extended to all products already known to be suitable for Medicines Homecare this would be up to 60% of the secondary care medicines budget. NHS Five-year-forward view anticipates the further extension of clinical homecare services to treat patients in community settings wherever possible. Given the choice, many patients choose the option to be treated at home rather than in hospital.

NCHA members seek to provide patient centered homecare services that are safe, cost effective and ensure seamless integrated patient care. The NCHA and wider industry stakeholders have been fully engaged in the DH Homecare Strategy Board (Hackett) workstreams (2011-2013) and are committed to the practical implementation of the RPS Professional Standards for Homecare Services (September 2013) supported by the RPS Homecare Handbook (May 2014).

Relentless, ad hoc market growth, compounded by medicines supply shortages and the exit of one of the larger companies from the UK market put pressure on homecare providers and the market suffered from poor service levels during 2013. Throughout this time and since, the NCHA has been pushing for the NHS to implement national strategic leadership in homecare particularly with respect to capacity planning. NCHA has continued to work in partnership with the National Homecare Medicines Committee to improve standardization, however, despite considerable efforts from individual member companies, there has been little progress on systems integration and automation of administrative processes and information exchange over the past 5 years.

Current homecare processes are predominantly paper based exchanges of information. There has been considerable debate and agreement that homecare services would greatly benefit from standardization of common elements and that considerable inefficiencies are generated from lack of interoperability between systems. Some of the benefits of increasing standardization and system interoperability are shown in Figure 1.

The overview of different systems used in homecare service provision is shown in Figure 2 overlaid on the Patient Journey Overview from the Hackett Technical Specification.

Enablers Business Changes Benefits Benefit Measure

Automation of order issue, goods receipt and invoicing process

Productivity improvement levels Improved

organisational performance

Real time monitoring and review of homecare providers

Integrated ordering, goods receipt / proof of delivery,

invoicing

Business Objectives

Patient experience improved

Faster / saferResponse

rate

Increased throughput

volumes

Increased financial

performance

Reduced cost base

Expand business

Increased capacity

Responsiveness of Service

Reduction in time spent reconciling orders, invoices & receipts

Introduction of integrated prescription processes

Ability to link orders to proof of

delivery

Ability to monitor in real time homecare

provider activity

Provision of electronic

prescription message

Standard prescription

formatStandard referral

format

Ability to match proof of delivery

and invoices

Reduced operating

costs

Cost savings

Reduction in staff costs and/or increased capacity

Reduction in drugs wastage – where services

ceased to be delivered

Ability to monitor homecare provider against

KPIs including costs

Reducing possibility of drugs being sent to deceased patients

Reduced risk of introducing unapproved

homecare providers

Reduction in end to end process times

Increased consultant compliance levels with

referral process

Chief pharmacist compliance with Hackett Report recommendations

Reduction in need for prescription checking

Introduce standard processes for patient referral and prescriptions

Figure 1: Benefits of interoperability and standardisation



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The patient’s diagnosis, clinical review and prescribing are managed within the Trust’s clinical system. By 2017 NHS Trusts should have implemented e-prescribing, however, in many cases an original paper prescription is generated, signed by the prescriber and physically transferred to the hospital pharmacy. At the hospital pharmacy the prescription is input into the pharmacy system where it is clinically screened and administratively processed so that the patient is registered for the homecare service and the prescription with an associated purchase order is sent to the relevant homecare provider. On receipt at the homecare provider the patient details are entered into the homecare provider’s system and the patient contacted to arrange their service delivery. The homecare provider’s system generates an invoice for the services provided which is sent to the Trust and entered into the Trust’s financial systems, manually matched with the purchase order and any proof of service delivery and processed for payment.

The whole processes is cumbersome, and prone to error as there are many data entry points and much duplication of effort. Patient safety can be impacted by delays in transmission of data and/or data being shared, but not recorded in an accessible format. There are Information governance risks arising from the sending of original hard copy patient information including prescriptions via post rather than as a secure e-message.



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Workshop Overview and ScopeThe Hackett Report and subsequent cross industry workshops have identified an ongoing need for standardisation of homecare processes and practices to support high quality patient care and support operational efficiency and market robustness.

The output from the Hackett IT workstream was the output based specification (OBS) and Technical Specification for a homecare system which would remove much of the manual and paper based order and invoice processing which is still prevalent in the industry today. These are included as appendices of the RPS Homecare Services Handbook (http://www.rpharms.com/unsecure-support-resources/professional-standards-for-homecare-services.asp). The next steps were to build a business case and/or seek funding for development of real world systems to support homecare activities.

Key requirements from OBS:-- Patient centric - Patient choice, Patient must feel in control.- Interoperable IT solution - linking Clinical, Pharmacy, Homecare Providers and Financial systems.- Any solution must deliver better care and cost savings for the NHS & Homecare Providers.- Fundamental requirement - Utilise open standards for data communication ecommerce.

Key requirements from Technical Specification- Flexible – so different systems can be bolted on.- Extendable – to allow for growth.- Manages Data Ownership – between the various systems.- And above all secure.

JAC and Ascribe (now EMIS Health) provide hospital pharmacy systems for 80% of NHS Trusts in the UK. Both JAC and EMIS Health are committed to working within an open standard for communication between homecare commissioners, NHS provider trusts and commercial 3rd parties. There is currently some automation of invoice messaging using commercial systems such as GHX and Medicator, which predominantly manage transmission of wholesale orders for medicines to/from hospital pharmacy systems. The Hackett review concluded that none of the systems currently available have been specifically designed and built to manage the end-to-end complexity of homecare orders and additional information governance requirements due to the inclusion of significant amounts of patient specific data including prescription messages.

Rationale Methodology, Aims & Outputsrationale

- NCHA is running this workshop and publishing proceedings so that the information is in the public domain and available to all stakeholders and system providers.

- Wide stakeholder engagement – consensus cannot be built overnight, but this workshop should allow good consultation papers to be developed and highlight areas needing more focussed attention.

- To allow open participation to find workable solutions together and positive risk/benefit ratios for all stakeholders.

- Hackett brought us together – Homecare is highly advanced in partnership working between NHS and industry – we must continue to show how fully integrated and streamlined homecare services can work in the “new” NHS.



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methodologyThis was an invitation only event. Invitations were sent to NCHA member companies, National Homecare Medicines Committee members, DH Homecare Strategy IT workshop members and deputies and representatives from NHS England, HISCIC, pharmaceutical industry, patient groups, pharmacy system providers and professional bodies. A wide cross section of stakeholder views were represented by participants attending the workshop. Participants self-selected which workshop group they wished to join.

Participants were given the following guidance:-- No reinventing of wheels - build on the good work already done.- Fill the gaps to facilitate “real” interoperability of homecare systems.- Uncover barriers to “real” interoperability and principles which can be used to overcome them.- Discussions are about the principles to be applied to any system.- Chatham House rules apply to the workshop discussions - participants are free to use the

information received, but neither the identity nor the affiliation of the speaker(s), nor that of any other participant, may be revealed.

Workshop Aims & outputsThis workshop aims to reach consensus where possible and provide substantive outputs which can be used by IT System providers to inform the development of their systems so they meet all stakeholder requirements. There were 4 workshop groups

- Workshop 1: Purchase order, invoice, payment.- Workshop 2: Information governance - Rx, and clinical data exchange.- Workshop 3 – Risks and Benefits of the Operating Models.- Workshop 4 - Data ownership and commercial confidentiality.

The outputs of this workshop will be public domain and available to all providers of IT based homecare systems to inform the development of their system offering. For the avoidance of doubt, nothing in the preparation for or execution of this workshop shall indicate endorsement by the NCHA for any commercial product or project – the NCHA intends to provide a level playing field and open industry standards to support the growth of the homecare market and the provision of high quality services to homecare patients.

It is planned to publish proceedings of the workshop on the NCHA website. NCHA have already been asked to present the report at the next NHMC meeting. Outside of actual system development, the outputs will be used to prioritise work to standardise elements to be included in the system.



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Workshop Reports

Workshop 1: Purchase order, invoice, paymentSummary of DiscussionAn urgent solution is needed to simplify and automate the financial administration of homecare services. The current manual invoice matching processes are resource intensive and unsustainable. Duplication of data entry into systems using differing data standards leads to data mismatch, error and payment delays. The workshop aim was to build on the process flow from the Output Based Specification and Technical Specification to agree the homecare process flow which identifies hand-off points and communication data sets. The strawman showing which systems would manage which aspects of the process (Figure 3) was accepted. The detailed process flows for invoicing and purchase order matching were accepted.

A paperless system is strongly preferred for managing homecare services with e-data sets to include prescriptions if possible. GS1, DM+D and SNOMED codes should be used and changes requested to include terms necessary for homecare wherever possible. Further standardized data sets should be developed for homecare where necessary.

Figure 3:- Detail of the Purchase Order and invoice matching process steps.



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Current issues which need to be addressed:-- Current hospital systems have not been designed with homecare in mind and there are many

workarounds, manual fixes and time delays in processing data place to support homecare. Most existing systems do not facilitate compliance with NHS SFIs and impair visibility of homecare transactions.

- Different NHS contract prices for medicines and ancillaries not specified in the tender or commercial contract are extremely problematic to manage in practice and the cause of much tension between the parties. The NHS tenders for “generics” on a regional basis whilst homecare providers often provide national services, so a patient in one region would have a different contract price for their “extra” medicines despite being on the same national homecare contract.

- Homecare medicines are expensive and systems must facilitate good service with minimum working capital and stockholding.

- Current systems usually deal in full packs, so purchase orders and invoicing of part packs is problematic.

- There are few built in system checks to ensure purchase orders and prescriptions are in accordance with the tender or commercial contract.

- DM+D does not equate to actual packs of commercially available product and not all homecare medicines and ancillaries are included.

- There is no national standard for homecare service codes including delivery options, medicine administration visits or self-injection training visits.

- Manual workarounds are often needed for deliveries of ancillaries and collections of sharps bins etc.

- Manual workarounds are often needed for deliveries, maintenance and collections of equipment.

Points of consensus:-- One to one relationship between prescription and purchase order and they must match.- One invoice per delivery; there may be many deliveries per prescription/purchase order.- Proof of delivery to be provided and accepted in electronic form and supplied automatically

with each invoice relating to a delivery.- A paperless system should be the aim without the need to send paper copies of prescriptions.- There need to be agreed processes to handle prescriptions for part packs.- There must be a step where the homecare provider accepts and confirms the order (e.g. GS1

advanced shipping note message), not just the invoice and Proof of Delivery message. This step must allow rectification of any mismatch between the order, prescription and contract specification.

- DM+D should be used to identify purchase order/invoiced items wherever possible.- Proof of delivery should routinely be available within 2-3 working days and in all cases within 11

days of the delivery date.- Process should be as shown in figure 3. The straw-man for the process was presented and

accepted by the group without substantive challenge.



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Workshop 2: Information governance - Rx, and clinical data exchangeSummary of DiscussionThe workshop focused on the clinical aspects of the homecare service including prescriptions and clinical information flows. The lack of real-time data sharing between primary and secondary care clinicians is a clinical risk; in homecare this risk is compounded as patient data is held by a number of organisations involved in patient care.

The OBS contains a wish list of data sharing, impacting all sections of the patient pathway and multiple organisations including patient’s ability to access and manage their own data where appropriate. Significant gains can be made with more limited data exchange as a first step before these wider aims can be achieved.

It was agreed that standardisation and e-data exchange would improve patient care, strengthen patient safety and improve the patient experience. The e-data exchange should include patient registration, prescriptions and purchase orders - even if the original signed prescription follows the e-data message by post to maintain regulatory compliance. Department of Health guidance on dispensing of hospital generate prescriptions is expected to clarify whether the original signed prescription must be held at the point of dispensing.

The key conclusions from the information governance workshop were:-- Systems and e-data exchange should include patient registration, prescription and purchase

order information to facilitate robust data entry checking avoiding errors when duplicating data entry and to ensure data consistency.

- A standardised “basic” homecare patient record must be maintained and shared between parties commissioning and providing the homecare service for that patient.

- The prescribing Trust is responsible for ensuring prescriptions are accurate, complete and timely. There must be a robust repeat homecare prescription process in each prescribing Trust under the responsibility of the Chief Pharmacist.

- A paperless system is strongly preferred. The physical transfer of original signed prescriptions to the homecare provider is for regulatory compliance purposes. This physical transfer adds to the information governance risk. The physical transfer of prescriptions does not enhance clinical governance where data integrity and security checks and secure, tamper evident data transmission processes are in place between the Trust and homecare provider.

- Clinical data exchange and feedback should be facilitated by any homecare system, backed by standardised operational processes to ensure clinical messages are written/sent and received/actioned appropriately.



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Current issues which need to be addressed:-- Prescriptions are often supplied late or incorrect as the repeat prescription processes vary.- Supply of medicines is controlled by the Human Medicines Regulations and there are legal

blocks to paperless working. Patient specific directions are used within hospitals, but the current strongly held view is that an original signed prescription is required to supply patients across organisation boundaries. Department of Health is due to publish guidance that will clarify this issue in September 2015.

- Patient specific directions may be appropriate where the homecare provider staff administer the medicines rather than dispensing to the patient for self-administration, but there is no clear guidance.

- All NHS Trust providers are expected to implement e-prescribing and e-medicine administration records for use within the Trust by 2017. These systems rarely consider the complexity of homecare services. NHS England Electronic Prescription Service (EPS) does not extend to hospitals or homecare.

- The original paper prescription is available (where service lead times allow) to the dispensing pharmacist in case of query but is rarely the primary source for dispensing in the homecare pharmacy. Therefore, there is no benefit from sending the original signed prescription to the dispensing pharmacy and this was viewed as a matter solely of legal compliance. Physical transfer of paper prescriptions represents an information governance risk, clinical governance and patient safety issues are addressed within other processes not the physical transfer of paper prescriptions.

- Purchase orders are usually raised in packs, but prescriptions are usually written in units leading to mismatch.

- Hospital clinical systems often unable to accept the clinical data currently submitted by Homecare providers.

- Many Specialist nurse and pharmacist prescribers successfully manage repeat prescriptions with manual processes – can we learn anything from them?

- Patients are able to request repeat prescriptions in primary care via the EMIS GP system, why is this not available in homecare?

- Some patients are using patient owned health records to support their treatment e.g. Patients Know Best, Health Fabric, Microsoft HealthVault etc.

- DM+D does not cover the majority of compounded products used in homecare. Compounded specials on the NHS Specials Database will automatically be added in due course.

- Current systems do not restrict prescribing or purchase orders to contracted products and services levels.

- Management of ancillaries for homecare contracts is mainly ad hoc and causes issues for all stakeholders.

- Registration information does not always include the patient diagnosis. This is important for the homecare provider to make appropriate dispensing checks and in some cases for pharma rebate claims.

- DM+D information is not always maintained by pharma.



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Points of consensus:-- Paperless systems are strongly preferred, electronic purchase orders to speed transmission of

data and prevent double keying is a great enhancement to clinical governance.- Technical capability and information system security is not the block to making electronic patient

data available to all those who are involved in the care of that patient.- The pharmacy clinical check must include check of the accuracy of the Purchase order message

and compliance with tender / contract terms. There must be an agreed national definition of what is meant by a clinical pharmacy check within a homecare service.

- Irrespective of whether a paper prescription follows the electronic message, all prescription data should be included in the Purchase Order message. If the prescriber’s advanced electronic signature can be added to the message, this will then constitute the prescription. It must be noted that very few hospital e-prescribing systems and neither of the key pharmacy systems meet the requirements for advanced electronic signatures as defined in the current regulations.

- E-Prescribing is preferred as this ensures authority of prescribers is controlled.- NHSE EPS strategy roadmap includes starting the review of how to manage private prescriptions

through EPS in for 2017. Agreement to push for homecare prescriptions this to be included under this initiative and for elements needed for homecare prescriptions to be ready for implementation on 1 Jan 2017 brought forwards.

- Basic Patient Record for homecare = Registration information; Must be up-to-date therefore full change control is needed. This patient data should be maintained in the hospital pharmacy and clinical systems, however, it will probably need to be persisted in the hub (at least in the short term) for audit purposes and as the required fields are not in the main systems and able to synchronise to the hub in real time.

- Systems must be able to deal with removal of a patient from the service, hospital admission of patient and take meds to hospital and/or patient on hold /suspension and restart medications at a later date.

- Must be updated 2-way between the hospital and homecare provider and if a patient is put on hold a message should be sent to the patient.

- Patient should have visibility and should have limited access for patient to update information e.g. to bring forwards a delivery due to holidays.

- Roles and responsibilities must be clearly defined and standardized as much as possible.- Responsibility of providing a correct repeat prescription in a timely manner rests with the

prescribing Trust. Homecare system prompts should only be used as a backup control process.- Patient’s requesting repeat prescriptions is not a suitable mechanism in homecare due to

the service cut-offs and constraints, this must be systematized to ensure continuity of patient treatment. So if the patient opts out of prescription request process, they may be unsuitable for homecare service.

- Chief Pharmacist is responsible to ensure the hospital has sufficient resource to run the homecare service including someone available during normal service hours able to deal effectively with clinical issues, prescription queries and urgent prescription requests.

- Nationally guidance for handling repeat prescriptions in homecare should be developed.- The hospital pharmacy system should control the repeat prescription processes including

pre-dispensing check information e.g. acceptable blood test results required.- Clinicians need to be able to access the homecare service information.- A hub system should facilitate real time clinical query management using standard specification

defaults time limits for response times and escalation if not resolved.- Ancillaries should be subject to the same requirements as medicines if invoiced separately.- If ancillaries are inclusive (i.e. not invoiced separately) they must be specified in the patient

registration details with expected usage levels and maximum supply quantities.- Compounded products should be out-of-scope for the initial phase of any development as they

add too much complexity – but keep on the wish list for future developments.- Snomed needs more codes for homecare. It should be possible to add them quite easily if there

is a defined “approved” list and a request is made to the NHSE CT Team for the codes to be added.

- Agree to use GS1 standards, DM+D, Snomed data and coding standards.



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Workshop 3 – Risks and Benefits of the Operating Models Summary of DiscussionThis workshop focused on the risks and benefits of the potential operating models to see if a consensus could be reached on the preferred operating model and how to take this forwards.

The operating models under consideration were:-- Status Quo.- Point to Point (Tech Spec option 1 & 2).- Hub (Tech Spec option 3).- One Overarching System (Tech Spec option 4).

Maintaining the status quo is “not an option”. One overarching system would take too long to develop and point-to-point connections were available now, but not widely used due to the complexity they generate. An overarching advantage of having a single system or hub is for the NHS to have “one version of the truth” - this is seen to be critically important for government funded services.

Any commercial solution could potentially cost the NHS more and give the NHS less control than if NHS commissioned/managed solution. However, the NHS does not have the capital and resources to invest in developing a new system for homecare and would not be able to use the expertise and efficiency of outside provider’s development teams, so there are positive and negative points to any commercial solution.

The conclusion was that a commercial hub model would be the best option for all stakeholders providing all stakeholders were engaged in the design process and concerns identified below could be addressed

Current issues which need to be addressed:-- There was a discussion about the lack of stakeholder determination to invest and implement

change, however there was clear consensus that the status quo was unsustainable, so the pressure wave pushing for change is increasing day-by-day.

- There was concern that the IT strategy for Homecare won’t be right as long as no clarity on general strategy for Homecare which is leading to individual hospitals/regions doing something different.

- Current developments are being driven from procurement efficiency perspective and not enough focus on the clinical aspects and patient care. Drivers for change have been commercial economics for homecare and system providers and the need to make savings in the NHS and there has been some perceived, if not real, lack of focus on the patient and enhancing clinical outcomes.

- The developments that have taken place over the past few years have suffered from the lack of standardization. There has been no consistency of approach from homecare providers and differing NHS Standing Financial Instructions (SFIs) have added complexity.

- The use of the existing EPS system for homecare has been proposed. The working assumption has been that EPS developments will be too slow to support homecare, so an alternative is needed, but this was challenged as handling of “private prescriptions” is on the EPS development roadmap for 2017.



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Points of consensus irrespective of chosen model:-- There was general agreement that automation of currently manual process and removal of

double entry points for data were essential to avoid a repeat of the homecare services issues encountered during 2013. Time is of the essence in finding and developing a new operating model.

- Some point-to-point systems are currently in place providing sporadic benefits. These point-to-point systems have proved complex to develop and sustain, have not been scalable in practice. In addition, they have not provided the overall system benefits and standardisation that are needed.

- Extending the use of point-to-point data exchange interfaces was possible, but result in a complex system and would not support the standardisation agenda.

- Automating the existing model in a point-to-point model would not fix the current mismatch of different data sets from different organisations.

- There was no appetite for the NHS to commission and fund developments- A single uniform end to end system that includes a patient portal is not preferred by commercial

providers and pharma who seek to add value to patients and to differentiate their services from their competitors.

- When considering hospital pharmacy systems there was agreement that the “standard” functionality should include the ability to manage all medicines and should not be care-setting specific. Any system must encompass robust stock management processes.

- Pharmacy systems must link with NHS internal EPMA (Electronic prescribing, medicines administration) and homecare provider systems using secure messaging. Data should be persisted only as long as necessary, then be deleted.

- Any homecare system must be validated.- There must be controlled secure access and links between e-prescribing systems and pharmacy

systems and automated process so that prescribers can amend products and dosages prescribed and pharmacy can change the purchase orders raised against any third party relating to that “prescription”. For clinical governance, there also needs to be an agreed process for managing prescription amendments, cancellations and replacements once they have been transmitted to the homecare provider for dispensing.

- There must be positive feedback loops using the GS1 messaging standards including Acknowledgement, Advanced shipping note, Goods receiving Note and invoice.

- The chosen model has to ”work” for all stakeholders.

Assessment of the different Operating Models1. Status Quo Risks

- Clinical Safety, Too many handoffs, can’t scale, can’t track anything.- Too much complexity, not enough consistency, high risk of process “going wrong” and affecting

patient care.- Poor patient experience around tracking delivery timeliness of medications.- Not an option.

Benefits & advantages- None identified.



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2. Point-to-Point Risks

- Limited visibility.- Solutions exist now but have not been widely used.- Site specific – makes it too expensive.- Risks perpetuating bespoke systems creating a highly complex system.- Too expensive, too long to develop, too complicated.- Homecare providers develop in different directions which could make it even harder to

standardise at later date e.g. patient portals.- Even if develop standards they will be open to different interpretation.- Too many different processes.- Patient may have multiple access points to retrieve information.

Benefits and Advantages- Companies already investing in point-to-point models. Relatively small change if there is

consistency of documents.- Allows differentiation between Homecare providers.- Lower risk option from development perspective, but will take time to develop and implement.- Could be a means to make progress towards a Utopian hub either Commercial or NHS Funded.

3. Hub Note:- The discussion assumed this would be a commercial hubRisks- Must have integrated data validation and data integrity checks.- May not be accepted and used by all stakeholders now and as the future commissioning

landscape changes.- Costs may be high, especially if a commercial provider gains a monopoly position.- Risk of lock in to this solution leading to challenge of changing to meet needs at a later date.- Concerns over costs and change control processes must minimize costs and allow upgrades

and system changes for each NHS Trust and/or Homecare Provider at different times.- Solutions developed may not meet the real needs of the NHS e.g. 60% of English NHS Trusts will

have Electronic Prescribing and Medicines Administration (EPMA) systems by end of 2016 and any solution must ideally link to EPMA as well as hospital pharmacy systems and have legal electronic prescriptions.

Benefits and Advantages- Flexible scalable, future-proof (if designed and developed with stakeholder engagement).- Good efficient financial flow achievable which will support survival of the homecare providers.- Can build in a generic accessible layer available to all NHS patients.- Vendors could pay for the development in the short term (but recognise that costs will eventually

be passed back to the NHS in some way).- Secure, single system, closed loop.- Conforms to pharmacy wholesale ordering model.- Reinforces standardisation of processes.- Still allows homecare providers to compete to provide a better patient experience.- Still allows pharma companies to provide bespoke patient support for their products.- Shortest time to implementation of a new model. Commercial funding is available and pilot

project already underway for a limited functionality homecare hub which automates much of the “back-office administration”.



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4. One Over Arching SystemRisks- It would take too long to build.- High cost, too expensive and unlikely to get government or commercial funding.- Too complicated, it would need stakeholder development on massive scale input from providers

and requestors.- Unlikely to deliver required system (compare to National Programme for IT in the NHS).- Can the NHS specify/ commission in a way that meets needs.

Benefits and Advantages- Potentially most uniform patient experience regardless of provider Authority.- One single route to place orders.- Ensure meets the needs of the NHS e.g. integration with EPMA.- No need for data exchange.

Workshop 4 - Data ownership and commercial confidentialitySummary of DiscussionParticipants were challenged asked to endorse or challenge the assumption that data is owned by the organization managing the system in which that data sits.

The key conclusions from the data workshop were limited- Clear definition is needed between raw data and analytics.- The need for a resolution that includes all interested groups.- A desire to ensure issues around use of data did not hold up the development process.- Observation that no NHS/DH delegates selected the data workshop even though it is a highly

emotive subject for many in the NHS.- Recognition that it must be resolved as commercial models that have a low unit cost to the NHS

will need to include data usage.

The subject of data ownership and commercialization is emotive, particularly within the NHS, but this was not a practical concern for those present as shown by their prioritizing involvement in other workshops over this one.

Current issues which need to be addressed:-- Pharma industry is adding complexity thorough onerous confidentiality and data sharing terms

in their commercial contracts which produce contractual conflicts for the homecare providers and inhibit their ability to share data with the NHS and provide national market statistics.



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Points of consensus:-- It was agreed that no stakeholders should block sharing of any raw data needed to ensure

seamless and safe patient care. Sharing of patient data is allowed under Data Protection Act and by Information Governance Toolkit providing it is shared for the purposes of patient care with other organisations having their own data protection registration and IG Toolkit Level 2 registration respectively.

- Standardised management reports which do not include patient identifiable data e.g. KPI reports and activity summaries are being agreed at national level and should form the basis of nationally available market statistics.

- Any discussions about data ownership and value must clear differentiate between analytics and raw data in terms of added value and access rights. Value is added to the anonymized raw data by the overlaying analytical processes and producing reports.

- There must be wider availability of anonymised raw data arising from a subset of the standard data sets for homecare services provided to NHS patients that allows NHS to provide national and regional leadership in homecare.

- A hub model is in the wider interests of all stakeholders and stakeholder groups. - Data sharing and availability issues must be resolved or will stall progress towards standardisation

and on the development of homecare systems and hub(s). - There was agreement to engage right people in stakeholder organisations to find a way forwards.

It is recommended that a data map be produced to facilitate those discussions. The data map should showing existing data flows which are “de facto” accepted by all participants today and the new data flows that will be created by implementation of a hub model.

Overall Summary and Conclusions:Homecare systems interoperability is critical to support the further expansion of homecare services in line with the NHS 5 Year Forward View of care provision in the community. Leadership and prioritisation are the two key things needed to move this issue forwards. The urgency of the current situation in homecare must be recognised; to make it a priority in order to both release funding and engage the interest of senior figures in the various parts of the NHS and other key stakeholders. The funding and detail technical work needed for the systematic approach to standardisation will follow once this issue has the attention of the decision makers and budget holders.

National Clinical Homecare Association (NCHA) and National Homecare Medicines Committee (NHMC) are working with other key stakeholders to support standardization in homecare. Whilst not directly systems related, the workshop participants supported both

- the NHMC driven initiative to have regional leads and a strategic national lead for homecare within NHS England and

- the CMU initiative to have a tender for homecare “generic medicines” on a national basis to simplify homecare pricing.

A fully paperless system which provides automated links between all the parties involved in a patient’s care is strongly preferred by all parties. Benefits would be to improve the patient experience, minimize patient safety risks and improve efficiency. Current hospital prescribing and pharmacy systems do not have homecare functionality “built-in” as standard. Coupled with the challenges of system interoperability between commissioners and homecare providers, this is hampering the scalability of homecare services provided to NHS patients.



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The commercial hub model provides a potential key first step in automation of manual administration processes. It should be seen as part of a longer term roadmap which addresses all the issues and provides the functionality described in the Homecare Handbook as supplemented in this workshop proceedings report.

Drivers for implementation of a hub model- Future sustainability of a robust homecare market.- Efficiency drives and cost pressures in all NHS funded services.- Patient safety issues arising from lack of robust & “real time” information sharing.- Patient choice – homecare will keep growing.- Patients demanding high quality service levels.

The commercial hub is the most realistic operational model that will meet the majority of stakeholder needs and can be realized within a reasonable timeframe. The substantive challenge from this workshop to the proposed commercial hub system is that it must include patient registration, hold and deregistration steps, not just patient information provided with each order.

Barriers to implementation of a hub model- Resources and cash.- How big a priority is this for the NHS?- NHS leadership of change in homecare.- The data question will not go away and must be resolved.

Recommendations for further work:-- Produce and agree the data set which comprises the basic patient record for homecare

(equivalent to the registration information).- Produce and agree the data set for the homecare purchase order and prescription information.- Produce a data map for a hub operating model. Resolve remaining data ownership and

commercialization issues which will delay or de-rail the development of interoperable systems. - Homecare services codes to be nationally agreed and included in DM+D and/or Snomed as

appropriate.- Produce a nationally agreed list of ancillaries for homecare including DM+D Codes.- Push for homecare prescriptions this to be included in NHSE EPS strategy roadmap and developed

to be ready for implementation on 1 Jan 2017.- Push Department of Health to publish guidance on hospital prescribing which will clarify the

legal status of the homecare prescription and facilitate a truly paperless system in homecare.

AcknowledgementsNCHA would like to thank our sponsors EMIS Health and JAC Pharmacy Systems who made this event possible.NCHA would like to thank Carol McCall for organizing the event.NCHA would also like to thank all those orgnanisations and individuals who supported and attended this event, but who cannot be named here as the workshops were held under Chatham House rules.

disclaimerNCHA does not warrant or represent that the material in this document is accurate, complete or current. Nothing contained in this document should be construed as medical commercial legal or other professional advice. Detailed professional advice should be obtained before taking or refraining from any action based on any of the information contained in this document.

NCHA Limited Registered Office: 105 St Peter’s Street, St Albans, Hertfordshire, AL1 3EJA Private Limited Company registered in England and Wales No: 6642621

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