NHS IT Wirral NHS Trust has been blazing the e-records trail for a decade. Involving clinicians closely has resulted...
in a success the national programme could do well to copy
Frank Burns has no problem getting his board to take IT seriously - he is, after all, the chief executive. He is also one of the most experienced, pioneering and respected IT project managers in the health service.
Burns heads Wirral Hospital NHS Trust which is now four years ahead of the national programme for IT (NPfIT) in the NHS, the government's multibillion-pound initiative to modernise the health service using new technology.
Wirral is rolling out an extensive, birth-to-death, community-wide electronic health records (EHR) system, having learned many lessons from its smaller-scale implementations of patient records dating back more than 10 years.
A Wirral briefing paper published on 2 September said, "These plans and the implementation of EHR mean that Wirral is now ahead of the NHS NPfIT which aims to produce a national Care Records Service by 2008."
Many trusts across the country are installing systems to allow hospitals and GPs to share a patient's electronic health record. Without data sharing, electronic records would remain in GP surgery systems; printed out and sent to hospitals for filing; or kept in separate systems by hospitals.
But few trusts, if any, have gone as far as Wirral when it comes to putting in place arrangements and systems for sharing patient data between GPs, hospitals and other healthcare organisations.
For example, the Wirral briefing paper says every household in the trust's area has received a leaflet explaining what it means to have an electronic health record.
There have been posters in libraries, pharmacies, hospitals, clinics and opticians. There have also been interviews about the project on local radio stations and advertisements have appeared in the area's newspapers.
Some 500 people in about 50 GP surgeries have been trained to use the systems, and family doctors are finalising agreements to share data with hospitals and other healthcare organisations.
Any patient who does not want their electronic record to be transferred to Wirral's central database can opt out, but only 13 out of 330,000 people have done so.
The approach and design of Wirral's system have helped to shape the national programme which is being implemented by five local service providers under contracts worth more than £6bn.
At the heart of the national programme is a care records service, to be provided by BT, which should hold summarised medical details on every potential patient in England.
Officials who run the national programme at the Department of Health hope that by 2008 all GPs will have allowed confidential details on their patients to be transferred to a central database which enables that information to be shared among authorised health professionals.
On a smaller scale this sharing of data is already happening at Wirral Hospital NHS Trust.
As a result of projects that date back to 1990 and even earlier, the trust has learnt - and is still learning - the many things that can go wrong when implementing health record systems. Some of these experiences have potentially major implications for the national programme.
For example, the trust told Computer Weekly that about 10% of the GP practices in the Wirral have not signed up to the electronic health record.
"Seven out of 61 practices are not signed up to the EHR," said Patrick Reed, director of Wirral Health Informatics Service, an IT offshoot of the trust. "Most of them are concerned that confidentiality issues outweigh the clinical benefits of sharing data. Some of their patients are concerned that they will be disadvantaged as a result."
He added, "The information governance issues of the EHR have been, and still are, the hardest part of a joined-up record. The technical side is simple in comparison.
"It is not surprising that some GPs have concerns. Legal and ethical advice has been taken throughout the EHR development. The EHR has been promoted by clinicians from the outset. However, we do not want to alienate those who have concerns and, therefore, their views are respected."
This hitch for Wirral has significance for the national programme because if 10% of doctors across England refuse to participate in a service to provide national care records, this would amount to a rebellion by thousands of clinicians.
Yet Wirral's implementation of electronic health records is critically different to the approach of the national programme: it already goes a long way to addressing the concerns of GPs.
In Wirral, if patients opt out of the EHR system, their records are not held centrally. They are held in electronic form but within the GP systems.
Under the national scheme, patients who opt out will still, whether they consent or not, have their sensitive medical details transferred from GP systems to the BT-built national database.
On this national system, opt-out records are not accessible to even authorised healthcare workers other than in "exceptional circumstances" but some doctors are concerned that there is still ambiguity about the definition of this phrase.
It is easy to see why the national programme's strategy, unlike Wirral's arrangements, requires opt-out files to be retained on a central database. If officials in Whitehall are to spend billions of pounds on a care records service they will want doctors to be able to access a patient's records, even one who has opted out, in an emergency.
It is likely, therefore, that the national programme will insist that all GPs in England consent to summaries of their patients' records being transferred to a central database. This could end in conflict between some GPs and officialdom - not a new experience for the Department of Health. Meanwhile, Wirral's local EHR system looks set to go from strength to strength.
Last week officials on the national programme said they are taking into account the experiences of Wirral. Similarly the trust's executives emphasised they are working closely with officials from the national programme for IT.
A spokesman for the NPfIT said, "The national programme recognises that Wirral and a number of other communities across the country have made significant progress in demonstrating the kind of benefits that IT can offer health care. We recognise that Wirral has a system that is functionally rich and from which the wider NHS can and will learn important lessons."
Critics of Wirral's systems point out that the trust does not have the latest hardware and software in use in all its healthcare organisations. But if success is measured by satisfaction and high levels of use by clinicians, it seems the trust has the most successful EHR system in England.
There again it should be a success. Burns combines his role as a trust chief executive with unsurpassed experience in implementing healthcare systems. He joined the NHS in 1966 and in 1997 was seconded to the NHS executive board as head of NHS information management and technology for 18 months. Burns was the main author of the strategy document for the NHS, Information for Health, which was published in September 1998. This provided many of the objectives which underpin the NPfIT.
Can a centralist, national programme hope to emulate the cautious, locally-driven success at Wirral? The 20,000 IT professionals in the NHS, 30,000 doctors in England, and taxpayers who are staking billions of pounds on the strategy, will wish with all their might that it can.
A local implementation of EHR
Why is Wirral rolling out local patient record systems when the government is spending billions of pounds on a national database of medical records?
Patrick Reed, director of Wirral Health Informatics Service, an IT offshoot of Wirral NHS Trust, said his organisation's electronic health record (EHR) system is an interim solution in preparation for national systems, "although obviously there are also clinical benefits from sharing data better between clinicians now".
Wirral's EHR evolved from nationally-funded projects to link patient data from disparate sources. A master patient index was established, which will also be needed in a national system.
Reed said that other benefits of the Wirral EHR are the lessons learned, especially the work done by the trust in addressing the concerns of patients and GPs over the confidentiality of records.
Specific benefits of the Wirral EHR include making summarised patient information easily accessible at the point of care and a reduction in the duplication of work and medical tests.
E-record lessons learned by Wirral
- Wirral NHS Trust says that "paper is still the most portable, lightweight and flexible data-collection device we have found - and there is no problem with battery life"
- The patient records system has helped to reduce the number of unnecessary X-rays, for example by suggesting to the clinician that a chest X-ray is not required as a routine pre-operation investigation
- Covering for temporary medical staff who are not authorised and trained to use the systems can present difficulties
- Wirral's main systems do not have all the features of software that is designed specifically for a department such as accident and emergency. That department would "obviously like us to provide all the benefits of a tailor-made A&E system along with the benefits of being fully integrated with the main [patient records] system"
- The system is not as smart as people expect. It is "not a replacement for a doctor's brain," says Wirral. "Sometimes the system is expected to do things it does not do. Although there are some clinical rules within the systems, we would expect doctors to take responsibility for their decisions." Wirral warns that, "this may become more of an issue as systems become even more sophisticated"
- If the system goes down, there needs to be printouts of the last results, what was last requested and the patient's current medication. Wirral's system has proved more reliable than expected but "there have been a few occasions over the 10 years of the system's life when paper has been vital"
- Capturing on the system all possibly relevant information from a patient's medical history can prove a problem if care and treatment date back many years
- By keeping track of pathology results, the software warns when a test that should have been done has not arrived back on the system within a certain time
Technology used by Wirral trust
Wirral's systems are managed in-house and have nearly 4,000 end-users on more than 1,000 terminals.
A main repository where all the operational data from feeder systems is stored for detailed analysis and reporting is an Oracle database. Updates to the system are carried out every 24 hours.
Primary hardware and software systems deployed include:
- IBM mainframe: VM/VSE (based at IBM's Warwick datacentre)
- Client platform: Windows/Dos PC
- Network location: attached to WHT wide area network
- Network protocols: SNA, TCP (via gateway), IPX (via gateway)
- Data accessibility: HL7/EDR Extract/Adhoc reports
- Enterprise data repository hardware: IBM RS6000, AIX
- Network protocols: SQL*Net
- Database: Oracle 7.3
- Data accessibility: Direct SQL*Net, Adhoc reports
Wirral also has a patient administration system from TDS dating back more than 10 years which it is seeking to replace.
Local caution may have lessons for national system
Wirral NHS trust's experiences in implementing an electronic patient record system go far beyond establishing that some GP practices may refuse to join a centrally-based system.
The trust has progressed cautiously, learnt lessons as it went along, and kept to the top of its agenda the need to consult clinicians early. Otherwise, systems may be technically adept and installed satisfactorily - but go largely unused by clinicians.
This has happened before in the NHS. The Department of Health acknowledged that there had been a reluctance to use the NHSnet, a national NHS network, according to a report of the National Audit Office in April 1999.
At the Healthcare Computing Conference in Harrogate last year, Frank Burns, chief executive of Wirral Hospital NHS Trust, emphasised the need to gain the early support of doctors.
"The clinicians who got involved [in Wirral's implementation of patient records] and signed up to the design and planning then signed up to the implementation of it and making it work," he said.
In contrast to Wirral's unrushed approach to implementation, which dates back more than a decade, the £2.3bn national programme for IT in the NHS wants its projects up and running quickly. This was emphasised in a document issued by the Department of Health in January 2003, entitled The national programme for IT in the NHS - key elements of the procurement approach.
The document listed the procurement principles which it said each project would adhere to, irrespective of the services being bought. The first principle listed was: "Rapidity: this means the commitment of all parties to do things quickly".
This commitment has led in part to the national programme having only limited time to consult doctors and nurses, and to contracts being signed in record time with local service providers.
According to some of those who work for the national programme, they would rather wait until systems are built and tested before launching even more widespread consultation exercises.
The hope is that once clinicians are shown what the systems can really do for them and their patients, they will become enthusiastic supporters of the national programme.
This approach has the advantage of speed: not taking into account the views of too many clinicians, while drawing on the experience of trusts such as Wirral, means that systems can be built more quickly.
But will clinicians want to use a new national system if they believe that only a limited spread of their views has been taken into account when the technology was specified? Burns has expressed his concerns in the past.
He said at the 2003 conference, "Installing these systems and implementing them are entirely different processes. Successful implementation requires a full-scale local change-management project. Getting this bit right at local level is absolutely critical and again I am not sure how the new strategy is going to address that.
"In my view, success... should not be measured by how many clinicians have desktop access to a clinical system, but by what percentage of clinicians are using their Pin number [to access systems] on a daily basis."
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