Building the Business Case
In the first article of this series we looked at how Trusts could identify 'portal fit' for their organisation. In this second article we look at the high level key points in any clinical portal business case.
When building the business case, each Trust will have its own format or template. In this article we have divided our key considerations into the typical 5 case model:
Benefits realisation is covered in the Management Case, however, it is Benefits Identification and realisation that generally causes the most debate. Benefits that are identified as cash releasing or that will have a financial benefit can be fraught with controversy and these should be reviewed and challenged in clinical and non-clinical forums before committing to the business case.
The most common issue befalling cash and non-cash releasing benefits in a complex environment is double counting. Reduced head counts are likely to appear in many other Electronic Patient Record Systems and are often over-ridden simply by overall corporate redundancy schemes. Unified Print Management may well have accounted for paper savings, a Laboratory System for label stationery savings etc.
By far the most benefit for Clinical Portal technology will be indirect quantifiable and non-quantifiable benefit space. In a rush to ‘balance the business case’ by concentrating on Cash and Financial benefits the right amount of time and effort is diverted away from the most likely long-term wins for Clinical Portals. This article suggests turning the normal process on its head and writing a strong case for Trust Boards to grasp the reality of such developments, in as much as these are long-term, strategic and evolving investments aimed at incrementally improving access to and quality of clinical information.
Trusts are often hard pressed to spend the required time on benefits realisation. The whole process should become a part of the programme start-up and managed alongside the project as a separate work stream.
Portal benefits really kick in when they extend beyond boundaries to primary care and ultimately to include the patients and carers. Working with the local CCG(s) to determine benefits and gain wider support of business case is essential. Don’t limit your thinking in terms of what a portal can encompass if functionality has benefits then demand these features.
1. The Strategic Case
No doubt your trust will have a series of business and clinical objectives along similar lines:
- Increased clinical and non-clinical efficiency
- Improved clinical outcomes
- Patient experience
With the Keogh, Berwick and Francis reviews, almost all Trusts will place a significant reliance on improving services and transformation of clinical practice down to technology. A key enabler of this will be Electronic Patient Records and/or Clinical Portals. The Strategic Case is therefore heavily based on the fact that technology, given the right project approach and senior management buy-in, can and will deliver the objectives.
2. The Economic Case
This case sets out the assessment of options Trusts have in regard to alternative approaches to address the strategic aims. Invariably this comes down to the following:
- An EPR can’t necessarily achieve the Clinical Portal extensions into CCG, external care settings and involve the patient more easily or more cost effectively
- Using single sign-on approaches to link existing systems into a common framework for clinical information access does not address patient access or make clinical information easily read and understood by all clinicians in all settings.
Again, the Economic Case really depends on your Trust’s starting point and other clinical projects in the current pipeline. Trusts may well be presenting EPR business cases for ‘big-bang’. For example, a Lorenzo deployment may have already procured and be implementing a ‘single solution’. In each scenario the Economic case is different but invariably still compelling.
Further sub-options can be explored in the Economic Case, for example, your Trust vs. the community, read vs. read/write portals. This is a Trust led appraisal but is best kept simple and therefore achievable in the first phase, even if benefits take much longer to realise.
3. The Financial Case
This demonstrates whether the Clinical Portal is affordable given cash or non-cash quantifiable benefits vs. the risks of not taking the approach.
Trusts will have their specific projection period which is typically five years. Also, Capital charges, VAT, depreciation, interest and other accounting rules will be specific to your Trust and so close finance involvement is critical.
- Present the figures clearly and concisely with detail following in tables.
- Divide analysis into Capital and Non-Capital, staff and non-staff.
- Ensure you have cash and non-cash releasing benefits start at a realistic point, not day zero for example.
- Whilst the whole cost will be subject to a formal procurement process, try to ensure that recurrent maintenance costs are considered (for software/hardware generally 20% of initial cost).
- Make sure you clearly and precisely document your assumptions and evidence when it comes to savings. If you have no such base internally, strive to provide external examples (other local Trusts, research etc.) that can back up your figures. Whilst this takes time it is vital.
- Represent ROI and break-even clearly in diagrammatic form if possible. Remember that the most important aspects of Clinical Portals are the qualitative and clinical safety benefits.
- Document the risks of not progressing the case in detailed form as well as those associated with a major project. Ensure that your Trust Board are left in no doubt about the importance of progressing but are aware that in any IT project there are risks. Mitigation and risk management must form part of the case.
4. The Commercial Case
This concentrates on the procurement options and approaches. Invariably this will involve either and open or restricted OJEU competition. Be realistic about the timescales and work closely you’re your procurement team to ensure that any proposal has some contingency for delay, commercial negotiation etc.
Often Trusts can build their own portals based on in-house teams working from a Trust integration platform or they buy a platform from which this can be achieved. Leeds Teaching Hospital and a number of other Trusts have taken this approach to good effect. The costs here are development time or additional development resources. Some frameworks can be used to good effect but the principle of allowing time and contingency apply just as much. In researching, consider open source solutions to control costs.
5. The Management Case
This presents the programme and project approach that the team intends to take, in detail. This has to cover the whole governance structure for the programme of work, executive sponsorship, stakeholder engagement, clinical safety gateways and an overall draft plan. Benefits Realisation is part of this project and a clear communication strategy is required. Risk management again takes centre stage and clinical/patient safety aspects have to be clinically led. Clinical engagement has to be woven into the programme and therefore has to be considered as a cost to the project.
It is a good idea to have a guide phasing plan with an indication of when benefits will flow from each phase.
A great deal of work is required to ensure a robust business case can be presented to your Trust’s Board. It may be worth investing in assistance from local communities, Senior Managers or external consultancies/agencies to verify and support the development of the case. With such complex systems we need to de-risk the investment or demonstrate the approach. Often small scale cost-effective pilots can help secure support of clinicians and give something tangible for Trust Boards to see and therefore understand.
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