The Wachter Review of Health IT: Final Report Robert M Wachter MD

1. Robert M. Wachter, MD
Professor and Interim Chairman, Dept. of Medicine
University of California, San Francisco
Chair, Health IT Advisory Group for NHS England
@Bob_Wachter
The Wachter Review of Health IT:
Final Report

2. Context of our Review
 NPfIT mostly failed to meet goals
 GP sector digitisation has gone well
 Five Year Forward View demands another
effort aimed at digitisation and interoperability
 Preparatory work (NIB, digital maturity
assessment), £4.2 B allocation by Treasury
 US had recent experience with digitisation

3. Office of the National
Coordinator for Health IT
~75%
EHRs in US Hospitals, 2008-2015
$30 billion in federal incentives under HITECH
$$

4. Things Now Getting Really Interesting
Traditional Enterprise
EHRs (Epic, Cerner, etc)
Consumer-facing IT (patient
portals, apps, sensors, etc)

6. A 7-year-old Girl’s Depiction of her MD Visit
Toll E. The cost
of technology.
JAMA 2012

7. Residents’ Room Vs. The Ward

8. 2014 Advertisement For AZ ER Job
Arizona General Hospital will be coming to The Grand
Canyon State later this year!! Located in a Phoenix suburb,
it’s a 40,000 sq-foot boutique general hospital.
Services offered include:
• Emergency Room
• Radiology Suite inc. CT, X-Ray, Fluoroscopy
• Two State-Of-The-Art Operating Rooms
• Outpatient Surgery
• 16 Inpatient Rooms
• NO ELECTRONIC MEDICAL RECORD

10. Pressure to
deliver high-
value care
The digitisation of
the healthcare
system
The Big Picture:
Two Transformational Trends
The Dominant Issue
Today
Prediction: The Dominant
Issue in 2026

11. Health IT: The Mother of
All Adaptive Problems
“… problems that require people themselves to change.
In adaptive problems, the people are the problem and
the people are the solution. And leadership then is
about mobilizing and engaging the people with the
problem rather than trying to anesthetize them so that
you can just go off and solve it on your own.”
– Ronald Heifetz, Kennedy School of Government

12. “You can see the computer age everywhere
except in the productivity statistics.”
-- Nobel Prize winning economist Robert Solow, 1986

13. The Two Keys to Unlocking the
Productivity Paradox
Improvements
in the
technology
Reimagining
the work
itself

14. SoS for Health, NHS
wanted to learn from
past experiences
(including US & UK)
to increase chances
of success in England

15. Members, National Advisory Group on Health IT
US Members
 Julia Adler-Milstein, PhD
 David Brailer, MD, PhD
 Dave deBronkart
 Terry Fairbanks, MD, MS
 John Halamka, MD, MS
 Christine Sinsky, MD
 Robert Wachter, MD (chair)
 Denmark: Christian Nohr,
MSc, PhD
UK Members
 Mary Dixon-Woods, MSc, DPhil
 Crispin Hebron
 Tim Kelsey (now Australia)
 Richard Lilford, PhD, MB
 Aziz Sheikh, MD, MSc
 Ann Slee, MSc, MRPharmS
 Lynda Thomas
 Wai Keong Wong, MD, PhD
Harpreet Sood, MD, MPH (Staff)

16. Advisory Group’s Process
~Ten 2-hour phone meetings
Two-day in-person meeting in England
Site visits to four trusts
Meetings with multiple stakeholder groups
I met with ~100 individuals
– Clinicians, patients, hospital leaders, researchers,
suppliers, social care, charities, policymakers …

17. Ten Insights Relevant to Our Review
1. Purpose of digitisation is not to digitise, it’s to improve
quality/safety/efficiency/patient experience
2. Clinician buy-in & engagement are absolutely essential
3. In U.S., a national programme that offered $s to subsidize
local purchases of IT systems meeting national standards led
to high level of implementation (10%90% in 5 years)
4. That said, advantages of UK national system (Spine, single
ID) should be leveraged
– Don’t overlearn the lessons of NPfIT
5. Govt’s tendency to overregulate IT should be resisted

18. Ten Insights (cont.)
6. Interoperability is crucial for many reasons, so bake it in
early (harder to do later)
7. User-centered design must be a core value
8. IT systems need to evolve/mature… need workforce (incl.
CCIOs) to do that, and some tolerance for messy early days
9. The IT system is just the backbone–must have culture,
people, flexibility to innovate/reimagine people/processes
on that backbone (adaptive change)
10. Be careful about overpromising: remember the Productivity
Paradox

19. Our Main Concerns at Start
 Some preliminary work on digital maturity, but no
clarity on who would get money, how much, and when
 Biggest worry: too little money, spent too fast, trying to
wire all trusts to meet “paperless 2020” could fail
 Need to balance equity with excellence: value of having
advanced trusts as shining stars and national/int’l leaders
 “If you think about the things that would get a CEO
fired, not digitising is not on the list”
Implementation Plan

20. Our Approach and Recommendations
 Divide implementation into 2 phases: now-2019, 2020-23
 Divide trusts into 3 groups:
– A (already digitally strong, with potential to be world class)
– B (digitally fair now and ready to advance to next level)
– C (not yet ready for major digitisation effort)
 Support implementation (in A & B now, C later) with
central resources to match local resources
– Local decision which system to buy (vs. NPfIT’s centralisation)
Implementation Plan

21. Recommended Phases of Digitisation
201 201201 202201 202 202 202
Phase 1: Now-2019 Phase 2: 2020-2023
Sort
trusts
into
Groups
A, B, C

22. Recommended Phases of Digitisation
• Approved plan
• £ (shared central/local)
• Work on own progress
• Partner w/ int’l leaders
• Help others in region
• Anchor regional
interoperability
• World class by 2019
201 201201 202201 202 202 202
Phase 1: Now-2019 Phase 2: 2020-2023
Group A:
Centres of
Global Digital
Excellence
(~12)

23. Recommended Phases of Digitisation
• Approved plan
• £ (shared central/local)
• Work on own progress
• Partner w/ Group A to
build local network
• Support regional
interoperability
• By 2019, be digitally
mature
201 201201 202201 202 202 202
Phase 1: Now-2019 Phase 2: 2020-2023
Group B:
Ready to
Digitise Now
(~1/3 of NHS
trusts)

24. Recommended Phases of Digitisation
• Approved plan
• £ (shared central/local)
• Be part of local network
• Work on own progress
• Partner w/ Group A & B
• Support regional
interoperability
• By 2023, be digitally
mature
201 201201 202201 202 202 202
Phase 1: Now-2019 Phase 2: 2020-2023
Group C: Not
Yet Ready to
Digitise
(remainder of
NHS trusts)
2023: End of national subsidies;
Difficult to meet quality standards
if still on paper; CQC deems
non-digital trusts out of compliance

25. Our Main Concerns at Start
 Combo of adaptive change/productivity paradox-> vital
to engage clinical staff, reimagine the work
 Key: individuals who can bridge worlds of IT and
clinical care (MD-, nurse-, pharmacist-informaticists)
 Problems of both supply and demand
– Few people in CCIO pipeline, no training programs, not
professionalised (interested folks changed plans after NPfIT)
– In trusts, small numbers, not enough time, budget, authority
Thinness of Clinician-Informatics Workforce

26.  ‘My authority comes from my clinical and technical
expertise rather than directly as a consequence of the title
and position in trust hierarchy. Not holding any budget or
having anyone report to me leaves me somewhat as an
advisor rather than leader.’
 ‘Yes – [need] some training to bring all CCIOs up to a level.
Yes, needs national recognition that this is really important
for an NHS to be fit for 21st Century. My organisation feels
a CCIO is a 'nice to have', not a mandatory role that
requires time, resource and investment.’
CCIO Network survey commissioned for Wachter Report, 2016

27. UCSF Health System
• $3 billion/year; 900 beds; 1.2M
outpatient visits/year
• Clinical IT workforce: 15 named MDs,
6.5 full-time equivalents
(nursing/pharmacy informatics on top of
this)
• CCIO=80% time, reports to CEO
Typical Large NHS Trust
• Similar size (albeit lower expenses)
• CCIO workforce: ~1-4 clinicians, <1
FTE total
• CCIO with ~2-3 sessions per week,
reports to middle manager
• Even adjusting for different resources,
markedly lower degree of support

28. Our Approach and Recommendations
 Insist on robust clinician-informatics workforce as
condition of funding
– Appropriate authority, funding, time
 Promote workforce training,
professionalisation, certification
– Allocate 1% of £4.2 B for workforce
 Need national CCIO to lead NHS digitisation effort
Workforce: Push and Pull
Prof Keith McNeil

29. Our Ten Major Recommendations
1. Carry Out a Thoughtful Long-Term National Engagement
Strategy
2. Appoint and Give Appropriate Authority to a National CCIO
3. Develop a Workforce of Trained Clinician-Informaticists at
the Trusts, and Give Them Appropriate Resources and
Authority
4. Strengthen and Grow the CCIO Field, Others Trained in
Clinical Care and Informatics, and Health IT Professionals
More Generally

30. Our Ten Major Recommendations
5. Allocate the New National Funding to Help Trusts Go
Digital and Achieve Maximum Benefit from
Digitisation
6. While Some Trusts May Need Time to Prepare to Go
Digital, All Trusts Should be Largely Digitised by
2023
7. Link National Funding to a Viable Local
Implementation/Improvement Plan

31. Our Ten Major Recommendations
8. Organise Local/Regional Learning Networks to
Support Implementation and Improvement
9. Ensure Interoperability as a Core Characteristic of the
NHS Digital Ecosystem – to Promote Clinical Care,
Innovation, and Research
10. A Robust Independent Evaluation of the Programme
Should be Supported and Acted Upon

32. “The experience of industry after industry has
demonstrated that just installing computers without
altering the work does not allow the system and its
people to reach their potential; in fact, technology can
sometimes get in the way. Getting it right requires a
new approach, one that may appear paradoxical yet is
ultimately obvious: digitising effectively is not simply
about the technology, it is mostly about the people….”
From Wachter Report, 2016

33. https://www.gov.uk/government/uploads/s
ystem/uploads/attachment_data/file/55086
6/Wachter_Review_Accessible.pdf