Comment and summary of highlights of a report on the Electronic Patient Record by the Health Committee of the House of Commons
As predicted, the Labour-dominated Health Committee of the House of Commons has avoided calling for an independent review of the NHS's National Programme for IT [NPfIT] but its report makes a series of compelling arguments for one.
The report finds that the programme has had some success. Locally some important battles have been won and in a few cases clinicians prefer their new systems to the old.
But the report's main finding is that the main objective of the NPfIT, a shared electronic, detailed care record, "remains a distant prospect".
That the Labour-dominated committee has agreed with suppliers, officials and the government that there should be no external independent review of the whole programme will not surprise Derek Wanless. Wanless, former Group Chief Executive of Natwest bank, who was a founding father of the NPfIT, has observed that there is an apparent reluctance to have an independent review of the national programme.
The determination of all of the directly-involved parties not to have an independent published review prompts the question: what are they afraid of? It's difficult to avoid the conclusion that they fear what a review would find.
Some staff at the Performing Right Society were so determined to prevent the board from knowing that an online membership system was in serious trouble that they asked a new IT director not to tell his fellow directors the truth. He did, however; and the full facts emerged. In the case of the National Programme for IT it's the board as well as the suppliers that shrink from every call for an external, published review, which is worrying.
But not having one could be recklessly complacent, perhaps dangerously so.
Summary of the main points in the report of the Health Committee
The report of Health Committee on the Electronic Patient Record is more than 100 pages long and jumps around in some of the important points it makes. Below is a summary of the report's highlights. For the purposes of this blog entry, paragraphs that make similar points have been put into sections, though there is still some overlap and repetition of comments made by the committee.
The paragraphs below are taken directly from the report of the Health Committee and are quoted verbatim. They are arranged into my section headings as follows:
1) Original NPfIT plan has changed fundamentally – and is now “vague and shifting”
2) Four years into the NPfIT there’s no agreement on what the electronic patient record comprises, whether it'll be secure, and when it’ll exist
3) Department of Health at odds with others on whether NPfIT is a success
4) More choice locally is needed
5) Water down further the role of NHS Connecting for Health in the NPfIT
6) Too much secrecy over supplier incidents that affect NHS sites
7) Security concerns – are breaches inevitable?
8) Lack of local involvement – hospitals at bottom of the food chain
9) Central NPfIT approach at variance with policy in other countries
10) Are promises of “sealed envelope” technology merely promises?
11) Importance of detailed care record is on a par with the car and the telephone
12) Officials say plans for a detailed care record have no completion date - but the private sector wouldn't have the luxury of consigning to infinity a key project objective. Is this a sign of a project in deep trouble? One supplier, BT, does have completion dates, however. Does anyone know what is actually happening?
13) The danger of shifting milestones
14) Delays in core NPfIT software leave trusts with old technology
15) It’s unclear what support will be given to hospitals and other organisations to change working practices to align them with new systems.
16) It’s not all bad news
17) Or is it?
18) Delays have contributed to scepticism among clinicians over the NPfIT
19) Set a deadline for "Lorenzo" system - and if not met let hospitals buy other similar systems
20) Suppliers, officials and the Health Committee are allies on need not to have an independent external review of the NPfIT.
Original NPfIT plan has changed fundamentally – and is now “vague and shifting”
NPfIT’s original vision for creating shared local records systems was set out in its specification document for the “Integrated Care Records Service”, published in 2003.
The document described the need for “integrated clinical information systems across the whole care continuum” and envisaged that “the patient will pass seamlessly through the system with…information flowing with the patient”.
Integrated local record systems were described as “the foundation and bed-rock for integrated care”. Integrated records systems would support “care pathways”, examples of which included a routine GP visit, a hospital referral to fit a pacemaker, and the A&E admission of a diabetic suffering a hypoglycaemic attack.
Electronic systems to support these “care pathways” were to be delivered in basic form by December 2006 and in full by 2010. However, the Department’s descriptions during our inquiry of local record systems, now referred to as “Detailed Care Records” (DCRs), bore little resemblance to this blueprint, and did not make reference to the 2003 specifications. Nor was it clear whether Detailed Care Records are still intended to support the integrated “care pathways” set out in 2003.
There was a stark contrast between the specific and detailed vision set out for the
“Integrated Care Records Service” in 2003, and the vague and shifting vision set out for the Detailed Care Records in 2007.
Four years into the NPfIT, there's no agreement on what the electronic patient record comprises, whether it'll be secure, and and when it’ll exist
… Determining exactly what information would be held on the new NHS Care Records Service systems was one of the main aims of the Committee’s inquiry. However, the information and explanations which we received from Connecting for Health about the content of the Summary Care Record changed markedly during the course of our inquiry.
… It is not clear exactly how long it will take to implement the Summary Care Record across England. Connecting for Health has stated that the full roll-out will take “several years” and separately that it will last “up to 2010”...
The Summary Care Record has the potential to improve the safety and efficiency of care especially in emergency situations when care is delivered by staff unfamiliar with the patient involved. The Committee supports the aim of introducing a nationally available summary record as soon as possible and deplores the delays and continuing indecision about its content…
The Committee was dismayed … by the lack of clarity about what information will be included in the Summary Care Record and what the record will be used for. Officials gave different answers to these questions on different occasions. The committee was told at various times that the Summary Care Record will be used for the delivery of unscheduled care, for the care of patients with long-term conditions, and to exchange information between primary and secondary care. It is little wonder that patient groups expressed confusion about the purpose and content of the Summary Care Record…
Patients in particular expressed concern about the lack of clarity about both content and consent [related to the electronic patient record]. Andrew Hawker, an NHS patient, offered an eloquent perspective on the situation: “I feel like a passenger boarding a plane. On board are technicians arguing about how the plane’s controls should be wired together, and who should do it. The plane has not had many test flights, and some of those have crashed. Meanwhile, flight attendants are handing out brochures saying how safe it all is.”
… Witnesses expressed concerns about the Department’s changing descriptions of the content of the Summary Care Record…
The Committee has also received inconsistent information about the patient consent arrangements for the Summary Care Record.
…We found it difficult to ascertain either the level of information sharing that will be possible when Detailed Care Record systems are delivered, or how sophisticated local IT applications will be…
… NPfIT’s success in implementing Detailed Care Record systems [should be the basis on which] the programme’s effectiveness should ultimately be judged… yet there is a perplexing lack of clarity about exactly what NPfIT will now deliver.
In its original specification documents in 2003, NPfIT established a clear vision for local electronic records systems. Four years later, however, the descriptions of the scope and capability of planned Detailed Care Record systems offered by officials and suppliers were vague and inconsistent.
Some witnesses suggested that parts of the original vision have been abandoned because of the difficulties of implementing new systems at a local level. We recommend that Connecting for Health publish clear, updated plans for the Detailed Care Record, indicating whether and how the project has changed since 2003. We also recommend that timetables for completing Detailed Care Record systems are published by all suppliers...
In spite of the obvious scale and ambition of the Detailed Care Record project, the Committee received uncertain and sometimes conflicting evidence about what Connecting for Health and its suppliers will actually deliver.
Most fundamentally, it was not clear what the shared Detailed Care Record will be able to do and exactly what information it will contain. Officials offered some information on this point… but [they] did not supply precise details about the appearance or specification of shared Detailed Care Record systems. Explanations from suppliers were similarly opaque… Professor Naomi Fulop of King’s College London, whose research has examined the delivery of NPfIT systems in the acute sector, succinctly captured concerns about the lack of detailed information on the Detailed Care Record: “What I would add about the detailed record is that it has not been communicated to people what it is.”
… Witnesses argued that even if some form of shared Detailed Care Record systems were delivered in the next few years, more clinically rich systems will take much longer to provide. In this context, the current lack of clarity about content and levels of information sharing within Detailed Care Record systems is worrying, especially when compared with the 2003 specification documents which provided a lot of specific detail about the project’s original goals…
… While local control over the new systems is a desirable goal, it is surprising that the architects of the Detailed Care Record were not able to provide a clearer vision of what is planned. There is an explanatory vacuum surrounding Detailed Care Record systems and this must be addressed if duplication of effort at a local level is to be avoided.
… Serious concerns were expressed regarding the lack of information both about how security systems will work and about the outcomes of security testing. We agree with these concerns and recommend that Connecting for Health ensure that BT’s planned security systems for its national applications are subject to independent evaluation and that the outcomes of this are made public.
... Other witnesses were scathing, particularly about the perceived inconsistency of the information received from Connecting for Health. Joyce Robins of Patient Concern commented that, “the grave impression is that they are making it up on the hoof”.
Department of Health at odds with others on success of NPfIT so far
[The] NPfIT is characterised by a centralised management structure and large-scale procurement from private suppliers ... The Department defended the progress made by NPfIT to date, arguing that the programme is on course to succeed. However, serious doubts have been raised, from sources including the Public Accounts Committee, about how much has been achieved and about the likely completion date. In particular, progress on the development of the NHS Care Record Service has been questioned.
More choice locally is needed
We recommend that:
- Strategic Health Authorities devolve responsibility for operational deployment by giving individual hospital trusts control over implementing their own new systems. SHAs should also devolve responsibility for implementing shared record systems across local health communities to their constituent Primary Care Trusts (PCTs);
- Strategic Health Authorities, Primary Care Trusts and hospital trusts be given the authority to negotiate directly with Local Service Providers and to hold suppliers to account, so that local organisations are not given responsibility without power …
NHS Connecting for Health offer all local organisations a choice of systems from a catalogue of accredited suppliers, as far as this approach is possible within the limitations of existing contracts.
… [local organisations should have] responsibility for negotiating with suppliers and for contract management …
… There are already signs of a change of approach to increase local ownership of system implementation. Accountability is being devolved through the NPfIT Local Ownership Programme and control for some users is being increased through GP Systems of Choice. These measures are welcome but overdue. There is a need to go further and faster with reforms of this type.
Water down further the role of NHS Connecting for Health in the NPfIT
Connecting for Health’s own role should switch as soon as possible to focus on setting and ensuring compliance with technical and clinical standards for NHS IT systems, rather than presiding over local implementation. Clear standards would allow systems to be accredited nationally but would also ensure that local trusts have a choice of system and control over implementation.
Too much secrecy over supplier incidents that affect NHS sites
Suppliers assured us that systems will be distributed in this way but the impact of the power failure at the Maidstone data centre, which affected 80 trusts, suggests otherwise. We recognise that lessons have been learned from the Maidstone incident. Nonetheless, we recommend that Connecting for Health instruct suppliers to publish details of all significant reliability problems along with a full incident log.
Security concerns – are breaches inevitable?
The sharing of unique smartcards between users is unacceptable and undermines the operational security of Detailed Care Record systems. However, we sympathise with the A&E staff who shared smartcards when faced with waits of a minute or more to access their new patient administration systems software. Unless unacceptably lengthy log-on times are addressed, security breaches are inevitable.
We recommend that Connecting for Health … Ensure that suppliers have clear plans for achieving access times compatible with realistic clinical requirements for all of their systems
Lack of local involvement – hospitals are at the bottom of the food chain
An important cause of the delays to Detailed Care Record systems has been the lack of local involvement in delivering the project. Hospitals have often been left out of negotiations between NHS Connecting for Health and its suppliers, and found themselves, as one witness put it, at “the bottom of the food chain”. As a result, they have lacked the incentives or enthusiasm to take charge of deployments. Increasing local ownership is now a key priority for the programme.
Central NPfIT approach at variance with policy in other countries
A significant difference between England and these other countries is that existing IT systems are being replaced by new IT systems purchased centrally by Connecting for Health on behalf of hospitals and other local organisations. This is possible largely because the majority of providers in England form part of the NHS.
In France and Canada, independent healthcare providers will purchase their own systems which must be interoperable with national systems. In the US, the Certification Commission for Healthcare Information Technology aims to encourage healthcare providers to purchase accredited, interoperable systems.
Are promises of “sealed envelope” technology merely promises?
Unsurprisingly, witnesses expressed concern that the software to create “sealed envelopes” [a software control that is meant to hide in the patient record particularly sensitive personal health information such as sexual diseases] has not been completed before the start of the Summary Care Records early adopter phase. Dr Peter Gooderham, a GP, complained that: …“sealed envelopes” have been advanced as an important method of protecting patient confidentiality. However, the technology was not in existence at the time the Department of Health described them… This appears highly unsatisfactory. Professor Douwe Korff commented that:
“I would not buy a car if the engineer told me he was still working on the brakes but by the time I was a few miles away he would probably have sorted it out.”
Importance of detailed care record is on a par with the car and the telephone
Most witnesses confirmed that Detailed Care Record systems would offer a substantial range of significant benefits. The very strong case for their introduction was summarised by Frank Burns [former head of NHS IT]: “Having to make the case for [local] electronic records is on a par with having to make the case for the telephone, the television, central heating and the motor car.”
Officials say plans for a detailed care record have no completion date - but the private sector wouldn't have the luxury of consigning to infinity a key project objective. Is this a sign of a project in deep trouble? One supplier, BT, does have completion dates, however. Does anyone know what is actually happening?
The Department did not provide an exact timetable for achieving the ultimate goal of the Detailed Care Record project, the delivery of the shared record itself. Its initial submission in March 2007 stated that: “ the transformation from paper to digital information will take place gradually up to 2010 and beyond”. The subsequent memorandum, received in June 2007, argued that specific completion dates could not be given because of the wide range of systems being delivered across different parts of the country and different tiers of care.
The Department …pointed out that Detailed Care Record systems will be built up incrementally and as such do not necessarily have a fixed implementation or completion date… Local Service Provider plans are all based on delivering incremental improvements.
BT, the LSP for the London cluster, provided a clear timetable for the completion of Detailed Care Record systems within this area. In its written evidence, the company stated:
“The foundations of the NPfIT system provided by BT are now built, operating and secure. Culturally integrating these systems so they become second nature for NHS staff is well underway. Over the next five years, the goal is to complete this programme.”
In oral evidence, Patrick O’Connell [of BT Health] set out a still shorter timetable for the completion of Detailed Care Record systems in London:
“…this year and next year [i.e. 2007 and 2008] we are rolling out the basic stand-alone capability…once it is established that we have the capability then we intend to link it together…In a stand-alone capability we should finish in 2009 and complete and integrated in about 2010.”
Thus, according to Mr O’Connell, all London hospitals, community providers and GP surgeries will have had their basic systems upgraded by 2009 and integration of systems to create the Detailed Care Record system will take place in 2010.
However, as discussed above, the exact content of the Detailed Care Record, and the degree of information sharing that will initially be possible, were not made clear.
CSC, the Local Service Provider for three of the five NPfIT clusters, did not provide such a precise timetable for the introduction of Detailed Care Record systems. Guy Hains [of CSC] told the Committee that the [iSoft] Lorenzo system, intended to be the main patient administration system software for hospitals and community providers, would be implemented for the first time “in the middle of next year”, suggesting an overall timetable some way behind that of BT.
Fujitsu, the LSP for the Southern cluster, did not provide evidence to the Committee.
Other witnesses were more sceptical about when Detailed Care Record systems would be delivered. The British Association for Community Child Health described detailed shared records as “a mirage with an ever receding completion date”.
The danger of shifting milestones
Dr Martyn Thomas [visiting Professor of Software Engineering at Oxford University] expressed grave concern about the loss of clarity about what the project will deliver and changes to the “milestones” for demonstrating step-by- step progress on the development of the Detailed Care Record.
He argued: “What typically happens is that people start redefining what the milestones meant, in order to claim success for milestones and to put off the day when they have to admit that things have gone wrong, and they start arguing about what it was they really were setting out to do at the beginning, so they start getting a bit weasely about what the specification really was…
Delays in core NPfIT software leave trusts with old technology
One witness described a trust buying new parts for its patient administration system from eBay because they were no longer available elsewhere; and frustration and disengagement at local level because of continuing delays, and particularly because the delays to new patient administration systems prevent more clinically rich systems from being deployed..
Witnesses also pointed out other problems caused by delays in upgrading hospital systems, including a possible impact on patient safety in hospitals with particularly old computer systems, because of reliability problems and difficulties in maintaining out-of-date
It’s unclear what support will be given to hospitals and other organisations to change working practices to align them with new systems.
The failure to give hospitals responsibility for implementing their own systems, and the lack of focus on changing local working practices to accommodate newly deployed systems, have also caused delays…
… Central agreement on new ways of coding, structuring and recording clinical information is of little value if such systems are not used at a local level. Officials commented that the implementation of clinical coding systems at the front line was likely to prove challenging, especially in secondary care.
Richard Granger [Director General of NHS IT] stated that: “It is going to be a long and difficult process to get the complexities of secondary care to code information in a way that it can be used outside of the location in which it was originally created.”
Mr Granger also commented that difficulties had been encountered when implementing Cerner’s Millennium system at hospitals in the Southern cluster because of the need to code more information at the point of care.
But officials did not say how they planned to address such problems on a wider scale. Nor was it made clear what support will be given to hospitals and other organisations to change working practices. Alan Shackman [former NPfIT programme facilitator] underlined the lack of focus on changing clinical processes:
“…the change management, changing the process…was going to be covered by the Modernisation Agency, which no longer is with us, so I struggle a bit to find any concerted way of helping make the process change happen whereas of course there is a most concerted way of actually getting the technology in...”
It’s not all bad news
Good electronic patient record systems can increase efficiency, reduce duplication and waste, and improve the cost-effectiveness of health services. Electronic Patient Record 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. It is right to describe [the] electronic patient record as “potentially a transformative technology”.
... It is clear that some elements of the Detailed Care Record programme, such as the creation of the N3 [broadband] network and the roll-out of hospital PACS [digital imaging] systems, are set to be successfully achieved.
Or is it?
Projects such as the N3 network and the deployment of Picture Archiving and Communication Systems are on the way to successful completion: Connecting for Health deserves some credit for these successes. However, the continuing delays to delivering new Patient Administration Systems and functions such as electronic prescribing in hospitals are a major concern. As a result of such delays, the shared Detailed Care Record remains a distant prospect.
Delays have contributed to scepticism among clinicians over the NPfIT.
There have been many causes of the delays in delivering new systems. One of these has been the expansion to the scope of the programme since 2002. Changes were perhaps inevitable given the scale of NPfIT, but it is disappointing that essentially administrative applications such as Choose and Book were given priority ahead of clinically useful Detailed Care Record systems.
It is also apparent that the original timescales for deploying Detailed Care Record systems were over-ambitious and did not take sufficient account of the complexity of replacing existing systems.
The lack of progress on implementing new hospital patient administration software, which has in turn prevented suppliers from deploying more sophisticated clinical systems, remains the biggest obstacle to delivering shared local records. The implementation of new hospital systems is more than two years behind schedule.
In London and the South, where Cerner’s Millennium system is to be deployed, there is some evidence of progress, as well as a timetable for completing implementation in London. Yet in the remaining three clusters, which are awaiting iSoft’s Lorenzo product, delays drag on.
Such delays have left many hospitals relying on increasingly outdated systems for their day-to-day administration.
Most worryingly, the failure to deliver systems on time has reduced the confidence of local clinicians and managers in the programme, something which has itself contributed to delays.
Set a deadline for "Lorenzo" system - and if not met let hospitals buy other similar systems
We recommend that Connecting for Health:
“… Set a deadline for the successful deployment of the Lorenzo system in an NHS hospital, making clear that if the deadline is not achieved then other systems with similar capability will be offered to local hospitals.”
Suppliers, officials and the Health Committee are allies on the need not to have an independent external review of the NPfIT
Amongst those witnesses to call for an independent technical review of the programme were the UK Computing Research Council and Computer Weekly magazine, but the clearest explanation of the case for a review came in a submission from a group of 23 “senior academics in computing and systems” …
Professor Thomas … argued that a review by external experts would be able to resolve issues which the programme’s leaders might be unaware of or unwilling to acknowledge:
“…my experience of carrying out those reviews is that people get blinded by the fact that they are too close to the project and they get compromised by the fact that they cannot stand back and admit errors.”
Officials and suppliers both denied the need for an independent, external review. Richard Granger argued that the programme had already been heavily scrutinised, for example by the National Audit Office, and that Ministers had therefore concluded that a further review was not necessary.
Guy Hains [of CSC] pointed out that suppliers were subject to regular reviews, both technical and commercial, and stated that elements of the programme were in effect reviewed every two months. Guy Hains and Patrick [of BT] O’Connell both pointed out that individual systems were subject to high levels of audit and testing.
Whilst we understand the reasons for this [an independent review of the whole of the NPfIT], we do not agree that a comprehensive review is the best way forward… many of the questions raised by the supporters of a review would be addressed if Connecting for Health provided the additional information and independent evaluation [on specific aspects of the NPfIT] which we recommend in this report… The programme has already been scrutinised by the National Audit Office, the Public Accounts Committee and ourselves …”