IT chiefs must win over the health service tribes

In the last budget the chancellor Gordon Brown pledged a huge cash injection - ring-fenced to protect it from being subsumed into...

In the last budget the chancellor Gordon Brown pledged a huge cash injection - ring-fenced to protect it from being subsumed into other budgets - to build a national IT infrastructure for the NHS. Ross Bentley speaks to someone on the NHS IT front line about the practicalities confronting local IT managers.

The NHS has never faced a bigger ITchallenge. Promises to modernise the NHS have come and gone but never before has there been the ring-fenced funding for IT that chancellor Gordon Brown promised in the last budget £5bn over three years.

Now health service IT managers must work out how to provide useful IT systems with their windfall. While suppliers, civil servants and consultants grapple with the high-level strategy, IT managers on the ground are charged with delivering value.

Janette Marson has worked in the NHS for 25 years, first as a clinician but for the past 14 years in information management and technology, much of that as a project manager. In her current role as assistant director for electronic patient records at United Lincolnshire Hospital Trust she is perfectly placed to comment on the momentous changes under way in the NHS.

Much has been made of the scale of the task of providing modern IT systems for the NHS - an organisation that employs more than a million people. The nature of NHS business means it has no useful point of comparison. "A significant problem with IT in the NHS is that we are trying to automate very complex processes but at the same time these systems need to be easy to use," Marson said.

"It is a lot less straightforward than developing, say, a manufacturing system. There needs to be recognition that clinical processes are enormously intricate. Take the whole patient journey - the process of getting through the hospital, from GP through outpatients, to assessments leading to diagnosis and interventions - there are so many variables."

But with all electronic patient records supposed to be in place by 2005, according to the 1998 NHS IT Strategy, some standardisation is necessary.

Marson said that standardised pathways of care for certain conditions have been introduced in some areas. They are commonly used for fractures to the neck or thigh and for heart attacks, for example. But patients are individuals and in many cases their journey through the system will be unique. This is where the difficulty in automating processes lies - in many circumstances the experience individuals have of the healthcare process cannot be standardised.

NHS IT must also meet the challenge of serving a user community that has more pressing priorities than learning how to use an IT system. This is why investment must to go hand-in-hand with a process of change management, Marson said.

"Previously we have implemented technical systems and the expectation has been that benefits will flow from merely putting a computer on a desk. We must identify new ways of working using technology as the enabler. This demands major investment in change management programmes at local level, including training and communication," she said. "People will only come on board if they are involved and their opinions are sought from the beginning."

The degree to which IT is already used in the NHS as variable. "Things are starting to change but the whole NHS is not marching together," she said. "For example in the research and diagnostic departments of hospitals there is an advanced level of IT being used, as you would imagine, but on a fairly typical NHS ward or community clinic you are lucky to see a PC and, in many cases, these are not used by clinicians."

Many doctors and nurses fail to see IT as adding value. "In many cases NHS IT systems only have administrative and demographic information on them. They do not help in the day-to-day job," Marson said. "Doctors write in case notes or on note pads at bedside visits and then have to enter the notes into a computer at the nurses' station or in their offices. In most cases this information never reaches the computer because it is extra work to input it. We need some kind of technology by the bedside so the doctor can input straight into the electronic patient record."

The final challenge for delivering electronic patient records, according to Marson, is the unique working culture within the NHS that can sometimes hinder progress. "In many cases we have been our own worst enemies," she said. "An element of tribalism exists in the NHS which has resulted in some professional groups being reluctant to share records. Doctors, nurses, therapists - all have different sets of reports and traditionally staff groups have held on to and guarded their own records." The implementation of an electronic patient record requires a multidisciplinary approach to record keeping, where all staff groups access and input to a single record for each patient.

"I've worked in hospitals where the doctor was the only person allowed to write in the medical record. There is a need to change cultures as well as overcome a resistance to technology. It is all about agreeing a way of working that will benefit the patient the most," said Marson.

At United Lincolnshire she is involved in ensuring buy-in for the local electronic patient record implementation from all user groups. "We have set up a series of project teams made of all of the different staff groups, including consultants, ward clerks, junior doctors, nurses and therapists. Feedback will enable us to go to suppliers and, rather than say, 'We want to buy a computer system,' say, 'This is how we want to work using IT in the future - what is your solution?' "

The recent DoH report, Delivering 21st Century IT Support for the NHS, described the new procurement strategy for IT in the NHS and aimed to put electronic patient record implementations on a fast track and eliminate much of the present bureaucracy and consequent delays. "At United Lincolnshire Hospitals Trust we hope to complete our business case to demonstrate the need to make this major investment by March 2003," Marson said. "After that we can begin discussions with suppliers and quickly move to implementation. By then we will have agreed our new ways of working and our organisation will be well on the way in preparing itself for this major change.

IT user's wish list
  • User-friendly technology

  • A system that supports the patient journey seamlessly across the hospital and other healthcare settings

  • Bedside technology to allow direct access to the electronic patient record at the point of care

  • A resilient system that does not crash regularly

  • Intelligent decision-support systems to aid in the correct prescribing of drugs

  • Electronic ordering to speed up blood, X-ray and other diagnostic tests

  • Access to knowledge databases that will help in the diagnosis and treatment of patients

  • Digital archiving to store X-rays and other images

  • Telemedicine - increased use of videoconferencing technology to promote remote diagnosis.

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