NHS CASE STUDYWeek 6 Seminar

INTRODUCTION The following section outlines England’s National Health

Service plans for fully integrating an IT infrastructure into the current workflow practice.

AIMS Radically change the face of NHS IT while drastically

reducing the cost of IT to the NHS. connect 30,000 GPs to 300 hospitals.

Prior to NPfIT and for the last 20 years, there were successive attempts made to introduce IT into the mainstream of the NHS.

To date, the wide adoption of clinical IT within the NHS has been patchy.

In particular, a new ‘National Care Record System’ will aim to encompass a fully functional EPR system.

THE BIGGEST COMPUTER PROGRAMME IN THE WORLD, EVER! In 2002, the British Government announced the award

of eight enormous IT contracts with a combined value of more than £6 billion.

The companies selected would introduce new IT systems to the National Health Service (NHS) in England Europe’s largest public sector organisation.

Contracts were due to run for 7/8 years.

Named the National Programme for IT (NPfIT)

Agency called NHS Connecting for Health (NHS CfH) was set up to deliver the programme.

THE VISION

http://www.youtube.com/watch?v=YJxTznwRzs4

WHAT WILL NPFIT PROVIDE? (1) An electronic NHS Care Records Service

improve sharing of patient records Choose and Book

electronic booking service to help patients in GP clinics to book hospital appointments

Electronic Transmission of Prescriptions (ETP) Transmission of prescriptions requests from GP clinics

to pharmacies. aimed at reducing risk through decision-support-aided

prescribing aimed at reducing prescription fraud.

A National Network (N3) providing IT infrastructure, network service and

broadband connectivity

WHAT WILL NPFIT PROVIDE? (2) ‘Contact’

NHS email and directory service to enable secure transmission of patient information

Picture Archiving and Communications System (PACS) capture and distribute X-rays, scans and other digital

images Healthspace

online personal health organiser to enable patients to record information such as weight, height, blood group, allergies, medication and food preferences.

NHS.co.uk website with over 200,000 pages of information for both

patients and care providers. Common User Interface (partnership with microsoft)

interoperability is the key to success - all elements of the solution being installed have to be interchangeable

NPFIT: MAIN COMPONENTS

NPFIT: HEALTHSPACE PORTAL

The ‘HealthSpace’ website will allow patients to access their SCR from home and has great potential for making care more patient-centred.

GP SUPPORT GP2GP

Enabling patients' Electronic Health Records to be transferred directly between practices.

GP Systems of Choice (GPSoC) GPSoC is a new scheme where the NHS will fund

the provision of GP clinical IT systems in England. Quality Management and Analysis

System (QMAS) Objective evidence and feedback on the quality of

care delivered to patients. Quality and Outcomes Framework (QOF)

Voluntary system of financial incentives for improving quality for GP payments.

NHSMAIL http://www.connectingforhealth.nhs.uk/systemsandservices/nhsmail NHSmail is the email and directory service specifically designed to

meet the needs of NHS staff. Here are some of it's proposed many benefits:

You can log on from any internet connection - at work, home or on the move

You can access the NHS Directory containing contact details for over one million NHS staff

You can send SMS and fax messages directly from email free of charge You are able to share calendars and mailboxes with other NHSmail users

across the NHS Your email address will stay the same throughout the duration of your

NHS career, even if your organisation changes It is the only BMA and Department of Health approved email service for

securely exchanging clinical data between NHSmail users It is protected by cutting edge anti-virus and anti-spam protection It's a centrally funded service that's free at the point of use A helpdesk is available 24 hours a day, 7 days a week You can share mail and calendar folders with colleagues; for example, you

can allow a PA to manage your diary or share emails within a team It offers the option to give colleagues access to your inbox or auto-

forward your mail when you're on leave.

NPFIT: MOST VALUED COMPONENT An important aim of most developed health systems is the

creation, expansion and linkage of electronic patient record (EPR) systems.

The introduction of EPR technology offers numerous and significant benefits. Storing and transferring patient information electronically has the

potential to significantly reduce clinical errors and improve patient safety as well as allowing clinicians to communicate more quickly and accurately and to identify relevant information more easily.

Good EPR systems can increase efficiency, reduce duplication and waste, and improve the cost-effectiveness of health services.

EPR systems can also make information much more readily accessible to patients, allowing them to assume more control over their health records and thereby become more active in their own care.

In addition, electronic databases of health information can be used for a range of purposes other than direct care provision, for example clinical audit and research.

THE NATIONAL CARE RECORD SYSTEM (NCRS)

For the NHS, implementing a EPR system is one of the main aims of the 10-year NPfIT programme.

The national EPR or ‘spine’ (NCPS) aims to provide local integration of clinical systems (Local NCRS) including: electronic requesting of radiology examinations ordering of laboratory investigations electronic laboratory reporting electronic prescribing and medicines administration.

NCRS revolves around the central data spine. A national repository of clinical information Combined national databases and application. Store key information about a patient's health and care

NCRS (2) the spine will store personal characteristics of the

patients: demographic information summarised clinical information

• allergies • visits to A&E• adverse reactions to particular drugs.

ensure security of systems at both national and local levels

provide extra services such as anonymous data for business reports and statistic for research and planning purposes.

finally, it will interface with all the local IT systems within the National Programme.

NCRS (4) Initial concept was to store ALL patient information in a huge

central database. this concept was too ambitious now, detailed information about all of a patients contact

with the NHS will be stored at a local level, where most most healthcare is administered.

the 'spine' will only hold significant summary items from the patient record but will include key functions of those local systems such as access control.

once implemented, the spine will allow NHS wide access to patient summary records.

those treating the patient will have secure access to the summary information to assist with diagnosis and care.

the summary record will also point clinicians to where full local records are held.

this should provide safer, more joined up care.

NCRS (3) Therefore, NCRS will create two separate EPR

systems: Summary Care Record (SCR) containing basic

information, available at a national level.

Detailed Care Records (DCRs) containing comprehensive clinical information, available only at local levels.

NCRS will also include: Personal Demographics Service (PDS), containing basic

demographic details about every NHS patient including name, address, date of birth, NHS number and current GP.

Secondary Uses Service (SUS) which will provide access to aggregated data for management, research and other ‘secondary’ purposes.

NPFIT: SUMMARY CARE RECORD The SCR will provide a high-level record of key clinical information including

allergies, prescriptions, summary medical history, operations and procedures.

An SCR will be created for every NHS patient, although patients can choose to ‘opt out’.

Sealed Envelope will allow patients to restrict access to particularly sensitive information and are an important safeguard for patient privacy.

The HealthSpace website will allow patients to access their SCR from home and has great potential for making care more patient-centred.

SCR is of particular value for: patients travelling regularly around England Unconscious patients receiving emergency care Unscheduled care for frail, elderly patients in the community Patients being treated out of hours.60

Maintaining the security of the SCR is a significant challenge. Each SCR will be potentially available across the country to a wide range of different

users.

NPFIT: DETAILED CARE RECORD Each hospital GP surgery will store a Local record systems, on which

comprehensive patient records will continue to be stored

Local systems will feed a subset of information into both the Summary Care Record and Detailed Care Record systems, and as such will remain the foundation of the records service.

The Detailed Care Record (DCR), which will be created by combining information from local systems and will hold significantly more detailed clinical information than the SCR.

It will be created by linking or sharing information from the systems used by local providers (GPs, hospitals, community providers and others) to produce a single, detailed electronic record which can be shared across the local health economy.

This means that some patients may have more than one DCR if they have been treated at organisations in different parts of the country.

The DCR is likely to contain details of past and current conditions, assessments, diagnoses, treatments and care plans

NPFIT: ISSUES (1) There is an expectation that clinical information will be entered at

source, by clinicians when they see the patient.

This raises a host of issues for clinicians. Some see patients on home visits and may not have appropriate

portable equipment. Many feel that entering data during a consultation with a patient

interferes with the engagement with the patient. In many cases, the data required by the system is structured to enable statistical analysis and reporting of the data.

However, clinical staff often wish to record informal, unstructured, notes to share with colleagues rather than final conclusions.

They are conscious that they could be held responsible for their clinical judgments and may wish to delay these decisions.

It has been widely reported that GPs (BBC, 2006), as well as other clinicians, are particularly anxious about the confidentiality of patient records and do not wish to enter information that could get into inappropriate hands.

NPFIT: ISSUES (2) As a result of all of these issues, clinicians often enter little or no

information of a clinical nature into the system and they have sufficient discretion to maintain this approach.

By contrast, administrative staff have limited discretion and the record is highly likely to contain the more factual information that they are expected to enter.

The response of the user community to data input has an impact on the user community when they come to use the records.

One intention of the programme is that paper records disappear but, in many circumstances, what is emerging is a mixture of electronic and paper records in which most of the clinical information is in the paper records.

This obviously affects how much information can be electronically shared between Trusts, the main objective of the NPfIT programme.

NPFIT: ISSUES (3) The widely expressed concern about the confidentiality of patient

records is also having a powerful effect on access to the electronic records.

Connecting for Health have introduced a smartcard system for all users of electronic healthcare records, which limits the holders access to the patient record to what they need to know.

This is determined by nationally established Role Based Access rules a doctor has more access than a nurse who has more access than a

clerk, etc.

When a user is trained, they are registered to use the system and issued with a smartcard that determines their degree of access.

However, other initiatives in the health service are encouraging collaborative team work across the disciplines involved in healthcare delivery, and differential smartcard access can make it difficult for team members to share information about patients.

NPFIT: ISSUES (4) Another initiative is the policy of devolving more responsibility for patient

care from medical staff to nursing staff, which increases flexibility in local organisational arrangements.

However, this can be lost if the access rules for the electronic records do not reflect this flexibility.

It is widely expected that, faced with these obstacles to access, clinical staff will find ‘workarounds’ such as sharing the smartcard of the most senior user, to enable them to work together to deliver patient care.

A particular example of this issue arises from the fact that to access a patient record a user has to enter their smartcard and password, a process that takes about 90 s each time.

The medical staff of the Accident and Emergency Department of South

Warwickshire General Hospitals Trust (Collins, 2007) have declared that, although it is against the rules, they will all use one smartcard, left in the computer for the shift, so that delays in urgent patient care do not occur as they each enter their own smartcard.

PRESS COVERAGE The project has received a lot of bad press. You may have

heard stories on the news which are always very pessimistic. Excessive delays

It was estimated that 151 acute hospitals would use the system by April 2007.

The actual number was only 18 in April 2007. Excessive overspending

It appears some hidden costs were overlooked. i.e. cost of training etc.

Some incorrect assumptions include: Doctors would welcome such a system with open arms (attitude

barrier had to be crossed as well as technical barriers). One size fits all solution is viable.

Some of the questions are being asked Did ministers really know what they were funding? Was there enough diligence into the solutions being offered or

did it come down to price? Is the architecture used right?

A ROUND UP OF ISSUES

http://www.youtube.com/watch?v=UqO03ipfqkA&feature=related

WHY SO BAD It appears that the NPfIT program may appear in text

books of the future as an example of a seriously bad IT project.

But what sort of misunderstandings have caused this. Wiki Source:

The project is not a simple technical problem, nor is it a complex technical problem.

It is a socio-technical problem. i.e. it has both technical constraints and social constraints,

namely, many users with varying requirements and expectations.

Perhaps to many things had to change to realise this system.

The NHS had to not only change their it infrastructure. They had to change they’re ways of purchasing etc to

facilitate this big project. General NHS policies are changing continually, so can

any IT system be so adaptable?

THE FUTURE: A SCENARIO … (1)

oRecently, at my exercise club, my blood glucose measured 112 mg/dl (milligrams/deciliter). This elevated value was sent to my composite record then to my PCP (Primary Care Physician) and to me. When I logged onto my computer, a flag indicated I had a message in my personal mail at my PCP’s web site. The message ask me to schedule an appointment soon because of the elevated glucose, as well as it was time for my annual physical exam.

oI accessed the clinic’s web site and scheduled an appointment with my PCP for the next week. The system identified some additional testing for me, and scheduled me 30 minutes before seeing my PCP for the tests.

oI also looked at my on record and noticed that my glucose had been climbing over the past 12 years to its current level.

THE FUTURE: A SCENARIO …o I arrived at the clinic, entered my health card in to a kiosk

registering my arrival. My eligibility was automatically checked and my health plan verified. I was directed to the lab for the blood drawing. I was also assigned a number which provided the linkage for me on this visit.

o Within 2 minutes of my scheduled time, a white board identifying me by number directed me to Exam Room 10. Here the provider performed the annual physical examination, sharing a terminal between us, and discussing how she proposed to deal with the elevated glucose with exercise and weight reduction. Since my cholesterol was also elevated, she decided to start me on Zocor. My dentist had recently started me on an antibiotic that intensifies the action of the cholesterol-reducing drug. My PCP suggested that I complete the antibiotic before I start the Zocor.

o She also scheduled me to return in 3 weeks to test my liver function because of the drug.

oThis information was put into my personal web page for download into my personal health record.

oThe exercise program was fed directly into my exercise machine, and my daily progress was monitored and recorded into my personal record. I also gave permission for the data to be uploaded to my PCP, since I thought the added pressure of another eye watching me would increase the incentive for my following the program.

oI was also given, interactively, a personal diet to help control my weight. I kept an on-line log in my personal health record.

oI also accessed information about the medication I had been given to reduce my cholesterol. I read about side effects and some of the controversy. I knew about the side effects; however, I decided to continue the drug at least for the next month.

oIn semester 2 – the Emerging Healthcare Technologies module will aim to explore some of these concepts!