Steve Bromham of Save9 summarises guidance on NHSScotland's cloud computing strategy and explores a comparison with NHS England's approach
It’s not difficult to imagine how - in first half of the last century - the pioneering manufacturers of motorised ambulances might have been challenged in selling their marvellous technological product to local and regional Health Boards. Attempting to convince civil ambulance services and hospitals that in order to improve patient survival rates in a medical emergency - they should procure faster, purpose-built mechanised transportation to replace their old horse-drawn carts.
It was only in the late 1940s that the National Health Service Acts made it a mandatory requirement for ambulances to be available for anyone who needed them. We take it for granted now – emergency ambulances are commonplace in our society thanks to this legislation and many of our citizens accept the benefits of this ‘technology’ without giving it a second thought.
NHSScotland's cloud computing push for digitally managing patient data & services
Moving forward to this century - in light of internet-enabled technologies - I’ve often wondered if patients’ lives are ever put at risk when a nurse, physician or surgeon quickly needs patient MRI, CT or Ultrasound scans - or a lab operative is delayed from digitally sharing critical patient test results with another healthcare provider. Perhaps an uncompromising IG or IS policy exists in their institutions - with staff fearing legal repercussions or senior managers worrying about financial penalties should their team ever consider ‘bending the rules’ in order to quickly transfer patient data via an unauthorised cloud software service.
I’m aware of unauthorised public cloud service use in Secondary care settings – something that can be very embarrassing for the SIRO, Caldicott Guardian or IT Manager when they find out it happened on their watch; despite a well-planned and executed IG communications strategy in combination with strict network controls or firewall blocking rules.
There is an array of complex legal and professional obligations placed on healthcare workers to help prevent this sort of thing - plus many official NHS/NHSS and internal guidance or policy documents – many of which describe acceptable usage of cloud computing services. Some apply to NHS England and others to NHSScotland. However - it may not come as a surprise to you that the justification for not adopting some public cloud services as a means to improve management or sharing of patient data can be down to this type of historical abuse (i.e. unauthorised cloud tools) and the confusion surrounding official NHSS/NHS policy plus the confusing array of professional and legal obligations that exist. Here are a few key documents - from a large list that we’ve identified...
|Applicable Legislation or Guidance||NHS-England||NHSScotland|
|Scottish Public Sector Cloud Computing Guidance 2015||No||Yes|
|NHSScotland Information Security Policy Framework 2015||No||Yes|
|NHSScotland Code of Practice on Protecting Patient Confidentiality||No||Yes|
|NHS Information Governance Toolkit||Yes||No|
|Records Management Code of Practice for Health and Social Care 2016||Yes||No|
|Information Security Management - NHS Code of Practice 2007||Yes||No|
|Confidentiality - NHS Code of Practice 2003||Yes||No|
|Data Protection Act 1998||Yes||Yes|
|Access to Health Records Act 1990||Yes||Yes|
|General Data Protection Regulation (GDPR)||May 2018||May 2018|
NHSS (NHSScotland) – an evolving acceptance of cloud computing
NHSScotland's acceptance of cloud computing technologies for digitally sharing patient data securely between healthcare organisations has rapidly progressed over recent years – driven by three key policy changes affecting the Scottish public sector as a whole and more specifically within the NHSS.
Because of a carefully worded NHSS statement published in 2013 - it seemed things might be about to change. That moment, in my opinion, was when the clock started ticking towards cloud computing acceptance across Scotland's NHS...
"...it is recommended that the most sensitive personal or corporate data is still not held in public cloud services until further notice".
Source: NHSScotland's Good Practice Guide for online document sharing and storage tools (http://www.ehealth.nhs.scot/wp-content/uploads/sites/7/documents/Good-Practice-Online-Document-sharing-tools-March-2013-27-March-2013.pdf).
Around this time there were examples of NHSS institutions enforcing their own strict cloud computing policies - e.g. NHS Forth Valley decided to add a key statement to their 2013 IS Policy and even mentioned specific cloud software vendors...
"Staff Must Not use cloud storage providers (Dropbox, iCloud, Evernote etc)."
I happen to agree that some of the big international consumer-grade cloud computing platforms are not appropriate for storing patient identifiable data - e.g. recent allegations that DropBox lost 68 million usernames and passwords in a data breach – a worrying thought for the average NHSS Board and their SIRO if their institution had decided to rush off and deploy this type of solution. To be fair – I believe DropBox, OneDrive and GoogleDrive have better than average information security management policies and procedures. Many in the IT industry believe that because these global businesses operate very large datacentre complexes and they are also high-profile international brands - they represent more of a target and also a challenge to hackers. One small breach in a massive multi-layered infrastructure appears to be able to wreak havoc - hopefully lessons will be learned and security improved.
Two years later - Scotland's Digital Future campaign eventually empowered the NHSS - as one of its targeted public sector institutions - with enthusiastically worded ‘top-down’ directives in the Scottish Government’s public service reform programme. NHSS could finally make a u-turn and officially approve the adoption of cloud computing technologies.
The cloud computing guidance document stated in its first principle (without prescribing or constraining any particular method of deployment, service delivery or business operation – e.g. private, hybrid, community or public deployment types)...
"Cloud based solutions will be the dominant approach for the Scottish public sector"
And the guidance goes further to outline cloud computing as a key strategic policy...
"Our overall policy position is that cloud computing is part of the strategic future of digital public services in Scotland. It has potential to fundamentally change the nature of digital public service delivery and, when appropriately utilised, can provide benefits in cost effectiveness, energy efficiency and speed of deployment."
Source: Scotland’s Digital Future: Scottish Public Sector Cloud Computing Guidance (http://www.gov.scot/Publications/2015/04/1707/downloads)
Shortly after this strategic announcement promoting cloud computing adoption across Scotland's public sector the NHSScotland Information Security Policy Framework was published; replacing NHSS Information Assurance Strategy 2011-15 and the NHSS Information Security Policy 2006 in one fell swoop (http://www.informationgovernance.scot.nhs.uk/isframework/).
This IS policy framework is a lot less prescriptive when related to patient data-sharing technology approaches and I suspect this was a deliberate action - reflecting the aims of Scottish Government strategic policy. It shifts operational information security and information governance management onto the individual NHSS institutions and Health Boards – offering guiding principles on information security best practice aligned closely with International Standards ISO27001 and ISO27002.
"Although there should be information sharing agreements with partners/suppliers and they may share the IT network and other computing resources it would simply not be practical for the Board ISMS to cover this whole landscape."
However - it is not a free-reign, as the framework requires that plans must be made to implement the necessary policy and procedural controls incrementally to safeguard the confidentiality, integrity and availability of patient information - the classic CIA triad for modelling information security.
"Each Board shall establish its own information security policy which includes components of the NHSS Information Security Policy Framework, national controls and standards as well as specific local policies."
So if you want a simple answer - as to what public, private or hybrid cloud computing services can or cannot be deployed across Scotland’s National Health Service - it is now clearly up to the respective NHSS institutions (more specifically their Health Boards) or executive-level decision makers in other Scottish healthcare providers to now decide...
"Produce a statement of applicability that contains the necessary controls and justification for inclusions, exclusions and whether actually implemented."
Healthcare professionals – understanding how better information sharing helps them to deliver better patient care
I think it is worth highlighting that the requirement for healthcare workers to rapidly and securely share patient data across disparate healthcare organisations is nothing new – anecdotally, the level of intra-organisational PID communications seems to be on the increase in a world of mixed private and public sector healthcare provision.
The continued dispersal of patient data across information silos managed by multiple healthcare providers appears to be on the increase – in contrast to overambitious centralisation projects like NHS 24 (NHSScotland) and the NHS National Programme for IT (NHS England). Two visions of single national data and service resources - so the Scottish Government’s stance on allowing NHSS organisations and partners to deploy their own cloud computing solutions seems well-aligned to meet the real-needs of local clinicians and their administrative colleagues.
The next step?
Appointing UK-based cloud computing service providers such as Save9 (note: please see Brexit article on potential geographic limitations of NHS data storage) that offer the right-levels of Healthcare IT sector experience, IG knowledge and demonstrable ISMS good practice (e.g. ISO27001 data centre provision and Cyber Essentials) seems to be a useful starting point for selection.
Managing Cultural Change
In summary - cloud computing is now officially part of the strategic future of digital public services in Scotland. However, service roll-out may be delayed for a lot longer than the Scottish Government might expect. NHSS Boards, their SIROs, Caldicott Guardians, plus IG/IT teams will need high-levels of assurance from UK public cloud computing providers that they will have the necessary information security and information governance safeguards in place.
A cultural attitude and sensitivity towards protecting patient confidentiality is held very dearly by many of the healthcare professionals I’ve worked with over the years. I believe some Cloud MSPs will find it very difficult to sell their 'one-size-fits-all' public cloud services into NHSS or NHS institutions if they can’t align themselves to this information governance mind-set.
Because of a potential cultural misalignment between hosted IT service providers and healthcare IT/IG professionals - I’m convinced we will see more community (shared-service) deployments of private and hybrid cloud environments - versus full-on public cloud adoption across NHSScotland - or even NHS England in the coming years.
The cost-savings and operational efficiencies of Hosted IT
Reflecting on the start of this article - i.e. the accelerated adoption of motorised ambulances in our last century as a consequence of legislative change - I believe we are now witnessing a similar phase of cloud computing technology adoption across the UK public sector. This time however – economic necessity has a big part to play too. Recently announced NHSS Health Board budget deficits will focus attention on IT projects that offer significant cost-savings alongside operational efficiencies and it is encouraging to see that the Scottish government recognises hosted IT services are less costly to setup, maintain and scale-out compared to traditional in-house IT.
The Scottish government now has a formal strategy in place for deploying disruptive and innovative digital services - on the hope that the entire public sector will play its part. Patient services across the NHSS could also be dramatically improved if cloud-based information management and sharing technologies become wide-spread. This is something that secure UK-based public cloud platforms built on scalable server and network virtualisation technologies can deliver quite easily and very quickly. Arguably with better manageability and security - assuming MSP assurances can be provided - and that all the agreed IS policies and procedures are rigorously adhered to and that any cultural IG mismatches are addressed.
If you have a specific Healthcare IT or cloud computing challenge - or perhaps you would like some assistance in specifying a secure data sharing solution that exceeds your information security and information governance compliance needs then please contact Steve Bromham at Save9 via our contact form or phone number below.