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Electronic patient records are supposed to be a cornerstone of NHS modernisation, replacing mountains of paper records and enabling different health professionals to access and record key patient information securely. These systems should improve the quality, safety and efficiency of patient care.
But from its very beginning the ambitious programme has been dogged by funding problems, lengthy procurement processes and technical delays, and individual NHS trusts have struggled to master the level of complexity involved.
According to the 1998 NHS IT strategy Information for Health, 35% of hospital trusts should meet the target for electronic patient records by the end of this month, rising to 100% by 2005.
But the latest Department of Health figures show that only five out of 173 acute NHS hospital trusts look set to have an electronic patient records system - which would include order communications, electronic prescribing and electronic care pathways - in place by this month's deadline. Few people working in NHS IT believe the 2005 target remains credible.
Against this background Sir John Pattison, NHS director for research, analysis and information, has announced that a new fast-track programme backed by major investment in NHS IT has been submitted to the Treasury for approval.
Speaking at Healthcare Computing conference in Harrogate last month, Pattison revealed that prime minister Tony Blair had chaired a summit meeting in Downing Street in February on how IT could be used to deliver significant, rapid improvements in NHS service delivery.
Under the approach the NHS will attempt to act more "corporately" in line with the national software licensing deal signed by the Office of Government Commerce with Microsoft in October. This will avoid the costs and delays of each individual hospital trust specifying and procuring electronic patient records systems individually.
"Part of the problem has been the NHS doesn't really recognise procurement costs," said Colin Innes, director of IT for Birmingham Health Authority.
There are no economies of scale in procurement - 200 procurements each costing £250,000 would cost the health service £50m, he added.
Now a standard national specification for systems is to be developed focusing on four core areas:
- National infrastructure
- Electronic records
- Electronic booking systems and
- Electronic prescribing.
The NHS will deal with fewer, bigger suppliers and attempt to slash byzantine system procurements that can take up to four years. Creating a short-list of up to five suppliers, or consortia, out of the 25 electronic patient records suppliers in the market will also trigger a market shake-up.
While each hospital will generally have its own electronic patient records system, the nationally-specified electronic records will be based on delivering joined-up care for specific disease areas - such as stroke and mental health - across a range of local health organisations. Essentially these will be stripped down electronic health records, the integrated "womb-to-tomb" record that was meant to grow out of individual electronic patient records.
Murray Bywater, managing director of health IT analyst Silicon Bridge Research, said, "The cynics would say that each time the NHS fails on IT, it stops and tries to move up to the next level of complexity."
Crucially this new approach does away with the six-level ladder framework to electronic patient records established in 1998, under which hospitals create increasingly complex applications from basic patient administration systems, up to electronic prescribing, digital transfer of X-rays and telemedicine.
Tony Eardley, director of South Staffordshire Health Informatics Service, said dropping the six levels of electronic patient records was overdue. "People have fixated a bit on levels rather than the functionality required in a hospital setting," Eardley said.
Though few hospitals yet have a full working electronic patient records system many have elements such as order communications in place. More than 30 NHS trusts are at various stages of electronic patient records system procurement, and a similar number are at different stages of preparing a business case.
For these trusts in particular the new approach raises a host of questions. Do they push on regardless of the new direction now being sketched out at national level, or sit tight and wait for further announcements?
Gwyn Thomas, new chief executive of the NHS Information Authority, stressed the revised strategy "consolidates on existing work", and does not undermine existing local IT strategies.
There is a danger though that local IT progress may stall as NHS managers wait for definitive guidance on the new approach from the Department of Health.
One electronic patient records system project manager, who has an electronic patient records business case due for approval, said he has been advised "not to push his business case too hard", and await further announcements from the centre.
Even if the Treasury gives the green light, additional investment will not become available until April 2003. So the coming year is likely to be one of planning and preparation - work on drawing up a specification is due to begin by the end of May.
Chris Russ, IT local implementation strategy programme manager for Wigan and Bolton Health Authority, said he welcomed the prospect of a clearer roadmap. "We have been waiting for a lot of national guidance, so it could be useful."
According the Paul Warner, head of electronic patient records for Southampton Health Authority, the answer is simply to just keep ploughing on and trying to balance the different political priorities. He said that in addition to electronic patient records, trusts are under pressure to simultaneously deliver systems to support the NHS' new national service frameworks for conditions such as stroke and cancer.
Terry Walton, head of IT at the Lewisham Hospital NHS Trust, said any central specification must be rapid and concise. "They've got to focus on the essentials and not get bogged down in details like how many bytes per field."
Though local NHS IT managers want a lot more detail and some have reservations, there is an appetite for a more corporate approach to NHS IT among local managers, frustrated by years of slow progress, lack of funding and piecemeal national guidance.
A revealing litmus test was provided by a conference debate the day before Pattison's announcements, when a majority of NHS IT managers backed the short-listing of suppliers and the development of national specifications.
But the question Blair will want answered is, can the health service harness IT to deliver significant improvements in patient care in time for the next general election?
The history of electronic patient records
1992: NHS IT strategy set goal of developing person-based systems, building to electronic records
1998: Information for Health laid out IT strategy for 1998-2005 and establishing six-level approach to electronic patient records, and goals for all hospitals to have electronic patient record systems by 2005 together with a first generation life-long electronic health record. Funding of £1bn committed
2000: NHS Plan set additional goal for all patients to be able to access their electronic records by 2005
January 2001: Building the Information Core: delivering the NHS plan - the update IT strategy in the light of e-government targets and NHS Plan - reaffirms commitment to targets for electronic patient records and electronic health records
20 March 2002: Sir John Pattison, NHS director for research, analysis and information, described fast-track, corporate approach to electronic records, based on standard specification, short-listed suppliers and core clinical functionality
21 March 2002: bid for additional NHS IT investment goes to Treasury