Doctors want IT suppliers to adopt the Snomed lexicon of medical
codes so that clinicians can iron out any flaws, but suppliers are
reluctant to invest until the bugs have been eradicated. Tony
Collins reports on the stalemate that could hold back the latest
NHS IT roll-out
Anthony Nowlan, a medical doctor and a director of the NHS
Information Authority, faces a classic Catch 22 problem.
He wants IT suppliers to adopt Snomed, a complex lexicon for
describing the care and treatment of patients, so that thousands of
doctors will start to use it and can report any flaws, allowing
developers to make the product more robust.
Refined in this way through a national experiment, as if it were an
NHS-wide drugs trial, Snomed could become a world standard for
clinical coding systems. It would help patients by, for example,
allowing doctors to check a mass of patient records and quickly
identify what treatments work best with particular
conditions.
The problem for Nowlan, and the future success of Snomed, is that
some IT suppliers want the product's basic flaws removed before
they will make a large financial outlay to adopt it in their
systems. At worst, suppliers suspect that the Department of Health
will promise to mandate the use of Snomed in the NHS but will
quietly drop it if structural defects persist.
"The principal limiting factor [in the take-up of Snomed] is the
development of systems," said Nowlan in an exclusive interview with
Computer Weekly.
Healthcare specialists believe the problem is a serious one, for
Snomed is a critical component in electronic health records which
would allow GPs and hospitals to quickly exchange details of a
patient's ailments and treatment. At present, paper-based records
are often missing, incomplete or in transit.
"The paper-based system of records is a shambles," said IT manager
Steve Ponting, who saw the problem caused by incomplete records
when his mother was in hospital.
The prime minister Tony Blair has promised that everyone in the UK
will have an electronic health record by 2005. But the successful
take-up of Snomed is likely to rest in part on whether suppliers
and doctors believe the department's claims that, after nearly four
years' work (and seven years on its predecessors) key parts of
Snomed are robust enough to use in service.
Nowlan is much respected, trusted and liked by his peers. However,
the Department of Health has, in general, a poor record on
delivering benefits to patients from national IT projects and has
lacked openness when projects have fallen behind.
In the 1990s, the department's credibility suffered when its senior
officials proclaimed as national successes projects that attracted
strong criticism from clinicians, IT suppliers and the House of
Commons Public Accounts Committee.
The projects included a clinical coding system, Read Codes version
3, on which taxpayers spent £32m. The Department of Health said in
the mid-1990s that it would mandate the use of Read Codes 3. It
never happened.
The Department of Health also proclaimed as a national success an
IT programme, Hospital Information Support Systems, which was
strongly criticised by MPs because it cost £106m but delivered only
£3.3m in benefits.
"They [the department's officials] have told us many times in the
past that something they have developed or been responsible for has
been robust and we have found to our cost it wasn't. Why should we
believe what they are telling us now?" said the director of a
healthcare supplier.
The credibility of statements by the Department of Health on the
success of its national projects may be further dented by its
response to an article published by Computer Weekly two weeks ago
that revealed the results of an evaluation of Snomed by about 40
reviewers. The "interim status report" said that most of the
doctors, nurses and other health specialists who tested Snomed
rejected it as unsuitable for use in the NHS.
An analysis of the official response to Computer Weekly's coverage
of the report will give little comfort to those who would like in
future to be able to trust the department's statements about the
success of its national projects. The Department of Health also
said in its statement:
"Snomed will not cost £100m to implement."
This gives the impression that Computer Weekly has got its sums
wrong. However, a report commissioned by the NHS Centre for Coding
and Classification, part of the Department of Health, estimated the
cost of implementing Read Codes Version 3 - the predecessor of the
Snomed, and arguably a simpler product - to be £100m. Also, the
Public Accounts Committee estimated the cost of implementing Read
Codes at "many times more" than its initial cost of £32m.
"The Snomed project cost $9m [£5.5m] over three years to
combine the two previous terminology versions, Snomed RT and Read
codes into a new product, Snomed CT [Clinical
Terms]."
This comment by the department failed to mention that the taxpayer
had already paid £32m for Read Codes.
"Despite the recognised difficulty of this sort of task,
the Snomed CT project was completed on time and to
budget."
Some IT specialists question the value of a product being completed
on time and to budget in 2001 if it has not been adopted by the NHS
by February 2003.
"This gives confidence in the ability of the NHS to
successfully deliver complex national projects."
The department is now in its 11th year of developing a medical
coding terminology for use in the wider NHS environment. Even if
Snomed were an unqualified success, should this give confidence in
the ability of the department to have success with far more complex
national projects such as electronic booking systems and electronic
patient records?
"The formative evaluation [the Snomed report as publicised
in Computer Weekly] was carried out using the first evaluation
release and subsequently two further releases have been issued with
major improvements."
However, the department's officials told Computer Weekly they were
keen to assess the full results of the tests on the first version.
They felt the tests would highlight any structural defects in
Snomed.
"It has never been the intention to launch [Snomed] in
April 2003 for use across the whole NHS."
The department published a strategy document in January 2001 which
said, "By March 2003 - migration to national standards for e-mail,
browsing and office systems completed and all NHS staff with
desktop access, and clinical information systems start to use the
Snomed Clinical Terms."
"There are over 1.3 million concepts and relationships in
Snomed CT and in an endeavour of this scale, for its first release,
the number of issues [836] is remarkably low at this stage of a
major project."
This referred to the Snomed report having identified only 836
flaws. But the department's statement failed to mention that the
836 flaws were found by only a tiny number of doctors who had
tested Snomed - and most of them had not carried out a thorough
evaluation.
Looked at in the round, the department's statement gives the
impression that any serious criticism of Snomed is unjustified and
that Computer Weekly is making mischief by publicising an interim
report on an outdated version of the product.
But Snomed is only one of a series of projects being run centrally
or regionally by the Department of Health. Its success, and to some
extent the success of other national projects, will rest to some
degree on whether the department can convince clinicians and IT
suppliers that it is tackling criticisms, not deriding those who
criticise.
If suppliers distrust what the department tells them, they will be
reluctant to adopt Snomed in any form, which would anger
clinicians, for all are agreed that the NHS needs to adopt
electronic patient records as soon as possible.
What is Snomed?
The culmination of more than 10 years work in the NHS, Snomed
uses clinical codes, a form of electronic shorthand, as a critical
component in computer-based records on the care of patients. It
allows doctors and nurses to record the problems of patients, how
they were treated, and the outcome. The system ensures that data
goes into patient records in a uniform way so that it can be
retrieved quickly.