MPs say EPRs essential but delivery in doubt

13 Sep 2007

Electronic patient record systems are vital to the future of healthcare in England, but there remain big questions and concerns over how and when they will be delivered by the NHS National Programme for IT.

This is the central conclusion of a detailed report on electronic patient records systems published today by the Commons Health Select Committee. It states that the delivery of the NHS Care Records Service (NCRS) has "been hampered by unclear communications and a worrying lack of progress on implementing local systems".

While work has begun on the first trials of the summary care record component of NCRS the report states that this is of secondary importance to the delivery of the local detailed EPR systems – the so-called Detailed Care Record (DCR) of NCRS - delivery of which has barely begun.

The Committee recommends that the Government ensures that regional Local Service Providers publish clear plans and a timetable for the completion of Detailed Care Record systems and sets a final deadline for the successful completion of the Lorenzo system.

The report also calls for more involvement by local NHS organisations and clinical groups in the implementation of DCR systems – due to be supplied by iSoft and Cerner – and more choice for users about what systems they will receive. The Patient Administration System (PAS) replacement strategy being pursued in England by NPfIT is contrasted with other approaches to EPR development underway internationally.

The Chairman of the Health Committee, Kevin Barron MP, said: "Whilst the Government is getting the framework in place they still have some way to go before patients and the profession can see tangible benefits of the new system."

The report spells out the huge potential benefits to patients of EPRs, which are being created under NCRS, but says that delivery of the project remains uncertain with elements delayed by up to two years.

While there have been successes such as PACS and the N3 network the report says that NPfIT's overall progress in other areas "has been disappointing". In particular it says CfH has largely failed to deliver on its core objective of clinically rich shared local DCR systems.

"It is on NPfIT's success in delivering DCR systems that the programme's ultimate effectiveness should be judged," says the report.

The Committee calls for a more localised approach by NHS Connecting for Health, the DH agency responsible for NPfIT, to speed up implementation of the programme.

In particular the Committee singles out delays in the delivery of local Detailed Care Records – the rich local clinical component of NCRS – as a concern. The Committee describes such systems as the 'holy grail' for the EPR programme, but according to the report it is "not clear when they will become widely available".

The Committee also says it is concerned that iSoft's Lorenzo system, due to provide the detailed EPR across the North and the Midlands, will not be trialled until at least 2008, leaving organisations relying on 'increasingly outdated systems' to support patient care. Such delays, it says, "have caused clinicians and managers to lose confidence in the programme".

It says that as a result of this and other delays "it is not clear when joined-up DCR systems will become widely available".

The report also says the Committee was unable to get clarity on what the systems finally delivered will do, "we found it difficult to ascertain either the level of information sharing that will be possible when DCR systems are delivered, or how sophisticated local IT applications will be".

It observes that while NPfIT's original 2003 specification documents established a clear vision for local electronic records systems "Four years later, however, the descriptions of the scope and capability of planned DCR systems offered by officials and suppliers were vague and inconsistent". Some witnesses, it says, indicated the original vision "had been abandoned".

"We recommend that Connecting for Health publish clear, updated plans for the DCR, indicating whether and how the project has changed since 2003. We also recommend that timetables for completing DCR systems are published by all suppliers."

Echoing previous NAO and PAC recommendations on NPfIT today's report also identifies lack of local ownership as a problem that must be addressed as a priority. The NPfIT Local Ownership Programme is a first step "but does not go far enough".

It concludes: "An important cause of delays to DCR systems has been the lack of local involvement in delivering the project. Hospitals have often been left out of negotiations between Connecting for Health and its suppliers, and found themselves, as one witness put it, at "the bottom of the food chain"."

The report's recommendations include giving local organisations responsibility for negotiating with suppliers and for contract management, "and offering users a choice of systems wherever possible". The GP Systems of Choice (GPSoC) model is recommended as a template for the wider programme.

The report also makes clear that it believes root and branch reform of CfH is needed if NPfIT in general, and DCR systems in particular, are to be successfully delivered. "We recommend that Connecting for Health switch as soon as possible to focus on setting and ensuring compliance with technical and clinical standards, rather than presiding over local implementation."

Elsewhere the report states CfH's centralised approach "will increasingly need to be modified, particularly if the DCR programme is succeed".

Commenting on the report for the BMA, Dr Vivienne Nathanson, the BMA’s Head of Science and Ethics said: “Public and professional confidence in the National Programme for IT is low and its credibility is at stake. Many doctors feel that they are seeing few returns for the investment in IT at a time when financial cuts are being made across the NHS."

Dr Nathanson also backed calls for better clinician engagement and local ownership: "We support the committee’s recommendation of increasing local ownership of systems. The BMA has also recommended that local organisations should be offered a choice of systems. Implementation lessons must be shared nationally so that mistakes are not repeated."

Liberal Democrat Health Spokesperson, Sandra Gidley MP, added: “This ambitious project has suffered from a lack of consistent direction." She added: "Many of these problems could have been avoided by better communication with staff at a much earlier stage in the process."

Link

The Electronic Patient Record (PDF)

Reader's Comments

Briefly it seems to say it was all badly managed

13 Sep 07 17:08

Briefly and terribly politely it seems to say that the CRS Project was very, very badly managed by NPfIT and thus the Department of Health. Can someone take on the challenge of training the DH in effective management? Right now I cannot think of one well managed project to do with frontline clinical care that is being led by the DH.

GPSoC Not Right way to go

13 Sep 07 23:04

GPSoC has driven a coach and horses through the chance that the NHS may get an end to end EPR. It will create a huge partition in the patient record; where in secondary care and community, one system is used, using the same information and allowing workflow around the patient - this record will be interfaced and summarised for Primary Care. By this act alone, the patient will not have a single electronic patient record centered around the patient, so some of the value of NPfIT goes out of the window because the DoH either does not believe in NPfIT or is too weak...or it does not understand what an EPR can deliver. (or all 3)

Open Source

14 Sep 07 09:52

The US veterans' Administration have a good solution (Vista) available free of charge. Imagine what could have been done with that - even if it had needed tweaking to work in the NHS, using British English the money paid for NPfIT so far could have employed hosts of programmers to enhance it.

GPSoC emphatically IS the way to go

14 Sep 07 20:02

To your previous correspondent, sadly, what NPfIT delivers is not a record that can be shared across secondary adn community care services - it is a siloed system but running in a data centre. The GPSoC model retains systems that deliver actual clinical value and gives a framework to build on them for the future. Congratulations to the committee for recognising this and saying so so emphatically

Incremental DCRs?

maryhawking@tigers.demon.co.uk

15 Sep 07 10:49

Has anyone looked at what is needed for a DCR as envisioned by the original NPfIT program? As a GP, I was able to purchase a system where the requirements for an electronic patient record for GPs had already been worked out: I have yet to see any work on what is required for a DCR (which appears to be the equivalent of an EHR as implemented in Andalusia: a regional patient health care record covering a population geographically - rather than organisationally - defined) Under Professor Protti's definitions (workshop 10 9 07), the hospital based electronic record would be an EPR (see Information for Health) and a GP record an EMR. AFAIAA, both Lorenzo and Millenium are/will be installed in Trusts as EPRs rather than DCRs: can someone point me to any work being done or systems developed to support real DCRs, fully integrated across all health care sectors, and the implications of scaling any solution (including access controls) to a patient population size of either 52million (population of England) or 72million (number of live records in PDS)??

Is a PAS part of original OBS vision?

sue.wilson@swbh.nhs.uk

16 Sep 07 08:54

Two statements which intrigue me:

"The Patient Administration System (PAS) replacement strategy being pursued in England by NPfIT is contrasted with other approaches to EPR development underway internationally"

"It observes that while NPfIT's original 2003 specification documents established a clear vision for local electronic records systems ........ Some witnesses, it says, indicated the original vision "had been abandoned""

Have to say these two areas have given me some concern.

I haven't ever really understood when you read the ICRS OBS (LSPs), where it said that we needed to replace the PAS with a PAS. If you read the OBS there are only two actual references to Patient Administration Systems.

If you also look at, for example, Waiting Lists in the OBS it actually comes under Demand/Access Management and states:

"The service shall be part of the fully integrated scheduling systems to link with: pre-admissions, bed management, rostering, capacity monitoring and planning, sterile services, anaesthetic functionality, perioperative (theatres etc) and transport"

I don't see that as traditional waiting list management in a PAS, more enterprise or multi-resource scheduling.

In the early 90s we enhanced PAS systems to support Contracting. Yet I believe that is half the problem today, as we have turned them from a clinical support system to an Information System. We appear to be continuing to do that with the 18 week wait. There should have been an imperative surely for local organisations to have invested in Data Warehouses.

Perhaps what should have been done is let local organisations procure their own replacement spine compliant PAS (if required) and let the LSPs focus on the integrated scheduling and other more advanced functionality as outlined in the OBS. After all we do have Data Standards for exchange of information.

Also, for me there is the question of Theatres and Radiology, when again the OBS quite clearly states they are part of an integrated scheduling functionality. So why are Radiology Systems and in some areas separate Theatre Systems, being implemented, which do not appear to have any planned migration path to the vision of integrated scheduling? The demand is today for support of multi-disciplinary teams working together within and across organisational boundaries and one-stop services.

I can understand and sympathise with the issues the South have had with their Cerner PAS solution, but for me the problem is not so much about the deficiencies of Cerner, but the fact that you are trying to replace old style PAS systems with advanced multi-resource schedulers, which Cerner does indeed have in Millennium - Apples and Pears springs to mind.

Hindsight is an easy thing and I do hate to be guilty of that, but I have often wondered if the focus on PAS replacement was something inherent from the IfH Strategy days and Levels of an EPR, without a real understanding of what the OBS was actually saying.

Personally, I would like to see less emphasis on PAS and more focus on the delivery of clinical functionality.

OBS Vision and supplier interests

17 Sep 07 10:45

The IfH vision was for locally joined up, clinically focussed systems. I think the focus on replacing all PAS systems comes from the NPfIT delusions that everything will be better if we outsource it, and leave the supplier to pick their subcontractors.

The failure to integrate scheduling through Radiology and Theatres comes from the changing commercial agenda, and the way CfH worked with suppliers and not the service, in allowing LSPs to select these solutions.

In the South, before a single LSP Radiology solution was deployed, the Care Record was changed, and it was obvious and loudly challenged that the Radiology solution should switch to be better integrated. This was quoshed in a very rare decisive move.

(Dis)Integration? No DCR, but a CUI and controversy over mobile technologies.

17 Sep 07 21:09

The Commons Health Select Committee state that specifications for DCRs are "vague and inconsistent". Why then, if the specification/implementation is unknown, can the user interface for EPRs be specified by Microsoft and the NHS? Surely this is a case of the cart being put before the horse? Until we have a model for how to store medical data, surely significant tracts of the work on the UI will prove redundant. Looking at things another way, may I respectfully suggest that the best chance of gathering data from front-line clinicians would be via "hands free" mobile devices that integrate well into their itinerant work pattern. Perhaps NPfIT needs to refocus on a model for the DCR, the viability of the CUI in the light of this model and the value of mobile devices.

Is a PAS part of original OBS vision? II

nhstechie@btinternet.com

18 Sep 07 00:49

... only in its purest form and certainly not as a bean-counting system or a waiting list management system which have nothing at all to do with direct patient care. These are secondary uses of information - reports on which should be produced from a local or regional data warehouse - not from a live patient care system.

The OBS reflected the high-level requirements of a patient-centred system designed to support direct patient care. It was never intended as a functional design document - the idea was that each LSP would, in collaboration with the NHS, produce detailed functional designs.

Delivery of the OBS was never intended to be through legacy software products but through new object-oriented applications utilising HL7 v3 messages to communicate with fully integrated departmental and social services systems - hence the long-forgotten term "Integrated Care Records Service" in the OBS title. Since the publication of the final version of the OBS, the programme has suffered a death of a thousand cuts. This started with PACS and Social Services Integration being declared to be outside the newly rebadged NHS CRS scope (except as added services at additional cost), followed by GP and departmental systems. PACS was later bolted back on, but not as a fully integrated part of the service, perhaps because it was politically sexy and relatively easy to deliver?

Four years on and CfH seem to think that inventing a new set of three letter acronyms will solve their problems. The LSP applications were always intended to provide detailed care records (to the old EPR level 5 and above) from about 2005 onwards. If what I read on EHI is true, we won't be getting EPR level 5 from any of the LSPs for quite some time. The confusion was always about what was intended to be in the "Spine" services with a constant debate between a thin and fat model - which anyone at HC2003 and HC2004 (when NPfIT used to participate in the conference) will remember being openly discussed from the podium.

Sadly, by HC2006 the shutters were down and CfH were reduced to the voice of one man berating his audience from the podium. Will anyone from CfH turn up at all next year - or will that be delegated to the poor SHAs too?

What is wrong with IT

19 Sep 07 12:14

Ah the oft quoted phrase 'bean counting and waiting list management has nothing to do with direct patient care'. An important statement because it encapsulates everything that is wrong with NPfIT and NHS IT in particular.

The statement is breathtakingly wrong of course. By far the majority of direct patient care is administrative. Your treatment is only a tiny weenie few brief moments with a clinical expert. The rest is trying to get an appointment before the Sun burns out, trying to get your prescription, taking your drug (which you invariably do at home), trying to get some information out of the clinical person about what is hurting you, reading the literature that’s pressed into your hand. Even if you need to have a procedure the majority of services you benefit from are cleaning, typing, electricity supply, food services and the rest. The reason why you are not prescribed that expensive drug is because the PCT are wasting lots of money on IT project managers. Yes, accountants actually matter.

If you want to find out how important all of these things are to patient care try stopping the meal trolley for a few days and watch them drop like flies.

When you go to see your doctor you aren't bothered about his fancy stethoscope. You want him to spend some time looking at your lump and making you better. You want to see you GP at a specific time so you can get back to sort your kids from school, not sit in a surgery for three hours worrying whether you have left the chip pan on.

The NPfIT is obsessed with 'clinical information', what ever the hell that is. When you had your last appointment and when you can possibly get a bed so you can have an operation IS directly linked to patient care. It can be life or death. Have a look at mortality rates in relation to waits for a heart by pass. Oh that sort of stuff is just bean counting isn't it? To reflect this obvious fact, Government initiatives target these important things. Get waits down to 18 weeks (good). Get costing sorted out so we know what things cost to do (payment by results also good). Try to get the clinical staff to work together as a team so patients can be seen and treat quickly (very very good). Put an electronic ordering system in place so people can start to get some choice about where they go (gasp needs a national computer system, very good). Get a proper meal rota so your granny doesn’t come out of hospital weighing a stone less than she did when she went in. Interestingly NPfIT is completely bereft of support for most of these things which actually matter. Even where it does you could easily implement local systems which would do as good a job.

Admin only seems to matter to people when it goes wrong. There is some strange assumption that admin is easy and should just happen. Its not a core part of the sexy health provision thing like what you see on the telly. You never see the bins being emptied in casualty. NPfIT is the same. Its all about 'joining up data' and some mythical benefit you get from something called 'electronic records'. Meanwhile someone just fell off their trolley because they over stretched trying to feed themselves and nobody knew about it and someone dies of MRSA because someone forgot to wash his hands.

IT people seem to live in a bubble where admin is something others get on with and is of no concern of them. But bad admin closes hospitals. Doctors and nurses are good and necessary. But they aren't the be all and end all of the patients journey. Now all those NPfIT enthusiasts, ask yourself this. What is the name of the person who cleans your toilet at work? Be nice to them, every day they save your life.

Bean counting

19 Sep 07 13:22

I agree with a large part of the "What is wrong with IT" argument - however what is NOT good for the NHS is the prioritizing the administration of specious targets. The wrong beans are being counted!

If your house repeatedly catches fire do you

1. build a fire resistant house?

2. improve your fire brigade's response time?

3. install air conditioning systems and set a target of a maximum internal temperature of 300 degrees celsius to be achieved by some date beyond the next ministerial reshuffle?

NHS answer - number 3 - every time!

'Choice', waiting lists etc. do not need a dedicated solution in other countries because there is adequate capacity.

Are computer systems going to create new capacity? Ironically a good computer system is likely only to increase the demand for investigations, treatments, beds etc as clinicians would spend more time with patients.

18 week waits are a classic target delusion - even if this had been a sensible approach it required joined-up primary and secondary care systems which barely yet exist - instead substantial human and technical effort is being put into workarounds which divert attention from far more worthy administrative functionality.

I believe that is what clinicians resent and what the NHS should be resisting. Instead it accretes call centres and paper shufflers with the opportunity cost born by the patient and taxpayer. Bad admin IS indeed closing hospitals!

Dr Malcolm H Duncan

Medical Object Oriented Software Limited

What is wrong with NPfIT ?

19 Sep 07 14:48

I don't always agree with NHSTechie, but the posting following his, and labelling local IT resource in with NPfIT is just wrong. As a hospital IT manager, I have put as much care into helping the porters get a system that worked for them, and working on intranet based meal requesting, as I have in making progress for clinicians, and IT can often recognise and help with the interdependence and 'two sides' of interactions throughout the organisation.

At an early stage, I raised a concern with NPfIT that they were only interested in getting clinicians, and at that, Consultant Medical staff involved in the Care Record development. Ripping our efficient systems out for a half developed/anglicised admin system never seemed a good idea.

Local IT staff are very in tune with the power, influence and value of Outpatients Administration managers, Theatre administrators and the many other disciplines that do not feature in the public's perception of the health service.

Our failing is not having enough time or money. NPfIT has robbed significant time in responding to endless vacuous requests for information and deadlines that go nowhere, and hardly any of the money earmarked for IT modernisation has come to the frontline to provide facilities or staffing to make this work.

I have used the bean-counting phrase too, old PAS systems were originally designed only to feed the Regional HQ and DoH with statistics. Anything more was down to local attempts to enhance and build real value to operationally run the hospital. In my area, this included getting information back to clincians and their secretaries, providing real value to simple problems like 'where in the hospital are my patients'.

So please differentiate between CfH, LSP and local IT staff with your criticism, in the same way as I'd recognise, and value the distinctions between a GP, a junior House Officer and a Consultant Surgeon.

What is wrong with IT??

nhstechie@btinternet.com

21 Sep 07 00:23

"Ah the oft quoted phrase 'bean counting and waiting list management has nothing to do with direct patient care" - oft quoted? I just made it up - fame at last!. "The statement is breathtakingly wrong of course. By far the majority of direct patient care is administrative."

Much as I love and depend on my administrative colleagues, the next time I need DIRECT patient care (e.g. CPR or, more likely, a stomach pump) I do hope it is administered by a clinician!

Seriously, you are entirely missing the point, which was that the resources within an EPR system (NPfIT, locally procured, VA or whatever) should be dedicated to delivering the patient record to the point of care. Anyone who has managed a legacy PAS system will tell you that running massive number crunching reports on a live system, say to produce the regular, largely pointless, bean-counting, CDS returns for the DoH will slow your system down to a crawl - unless you over-engineer the system so much that it becomes prohibitively expensive. In today's 24/7 world, there is no such thing as a quiet period when there will be absolutely no-one using the EPR - so running these reports overnight is no longer an option.

You are right, the scheduling of appointments, prioritising treatment, noting patient histories, efficient bed management, ordering of services (including meals) which you quote are all part of an advanced EPR system but they have NOTHING whatever to do with "waiting list management" which is all about ensuring the hospital meets politically-set targets designed to convince the public that things are getting better. The reverse is true, possibly because so much collective effort is spent measuring the length of time between referral and treatment - irrespective of the urgency of the individual patients condition.

"Waiting list management" in this context means managing the admissions system to avoid the magical 18 week RTT being breached - even if it means treating relatively comfortable patients with non-urgent conditions before treating those whose painful conditions need urgent treatment.

For the record, this particular NHStechie is an old-fashioned practical electronics engineer who drifted into IT when Bill Gates was just another chancer trying to flog an operating system. As well as the EPR, he also manages all his Trust's admin systems (Finance, Estates, Reporting/Performance datawarehouse, HR etc). The person who cleans our toilets is called Mary and has just recovered from an operation.