The benefits of electronic healthcare are making themselves obvious in a range of areas across the UK's health service. There lies the challenge: how to get a coherent electronic infrastructure in place, rather than running different pilot schemes, within a sector split up into different authorities and trusts, each with their own budgets and priorities.
It is the job of the NHS Information Authority to tackle this problem. It has done so with a £1bn information management and technology strategy intended to provide a framework where online healthcare is developed to meet the targets of the Government's overall strategy for the health service, published in July as the NHS Plan.
The health service's flagship IT project is NHSnet. Without a secure, reliable communications network to link primary care, hospitals and administrators, major advances in modernising the NHS cannot be made. But over the past year, NHSnet has hit several obstacles. By the end of 1999, only 2,500 out of a possible 9,000 GP surgeries in England, were connected. It could be 2002 before all English general practices are connected to NHSnet.
GPs were initially deterred from signing up for NHSnet by the call costs. But changes to the system have made this less of an issue. Fears over security remain a major concern, particularly when use of the network changes from administrative matters - such as e-mailing consultants to book appointments, checking medical details on the Internet - to clinical areas, where highly confidential patient records need to be transmitted.
With patient information now being computerised, it is the responsibility of the National Confidentiality and Security Advisory Body, set up in March, to set standards for security in this area. All other area of information security, covering case notes, X-rays, appointment letters, prescriptions, and personnel details, come under the NHS information Authority.
The NHS Information Authority has put in place a national security information policy and appointed eight regional security co-ordinators. These are moves that have been applauded, but some are concerned they may not be enough.
"The rules are clear and are there to protect the NHSnet as a whole," says Phil Ryan, head of information security at Internet security specialist Peapod. "If an organisation connects to NHSnet, they must not connect directly to an unprotected network. If they do, they must put security measures, such as a firewall, in place that meet minimum standards.
"But quality of local implementation varies and it is not unfair to say there is not manpower and resources available to the Information Authority in its eight regions enabling it to do thorough and regular audits."
Dr Paul Bromley, a GP at Readesmore Surgery in Congleton, Cheshire, agrees security standards can be hard to implement, for instance in smaller practices, where they may be seen as inconvenient. "We need stricter practice regulations on security, such as ensuring someone logs off every time they leave their machine," he says.
Despite these fears, GPs have become more reassured about security policies within NHSnet. Over the course of the past year, progress has been made in getting them connected. In Scotland, 99% of 1,065 general practice surgeries are now linked to NHSnet.
But a recent study by the Forth Valley Health Board into the effectiveness of NHSnet in Scotland found variations in levels of training and usage of the network. The study says this "highlights the danger of allowing local decision making within a national initiative". These words could apply not just to NHSnet but also to every area where the health service is attempting to modernise existing practices.
Given the localised structure of the NHS, the Information Authority faces challenges in co-ordinating and streamlining local initiatives. E-procurement is an area the health service could potentially benefit from major cost savings. But e-procurement is not one of the 20 areas on the list of the NHS Information Authority's programme of work. The authority is also working with the NHS Procurement and Supply Agency to provide national standards for online procurement and develop electronic catalogues. Mike Singer, managing director of Elan Technologies, which specialises in healthcare systems, says that while the aims of the NHS Plan are excellent, they will be difficult to achieve, given existing structures and that the organisation has so far failed to streamline its procurement processes.
In general, although money is always a big issue, online development has focused on the benefits of improved services for both healthcare providers and patients. One of the biggest initiatives is getting patient records online. More than a dozen pilot projects are running, covering various aspects of electronic record-keeping, such as linking up patient information kept in different care centres and developing integrated care for patients, involving not just the health service but other agencies, such as social security.
Many in the health service, and in the IT industry supplying it, have welcomed these initiatives. In particular, they welcome the publication of a national plan for IT development. "Clear guidance from the centre is important, in all areas," comments Steve Graham, operations director at software firm iSoft, which supplies an integrated electronic record package to several healthcare organisations. "These issues are now being worked out."
The NHS Information Authority has set clear goals for implementing electronic patient records. It has published a six-stage strategy and has told all trusts they must reach a third of these by 2005. This means implementing basic patient administration and departmental systems, a master patient index, online clinical ordering, results reporting, prescribing, and the ability for different professionals to plan integrated care for patients, all online.
Some think these targets may be counterproductive. They say NHS trusts will take the targets as a minimum goal, rather than striving for the full six levels. Beyond the first three, which are mainly administrative, the next three stages go to areas with clinical implications. These levels provide electronic access to knowledge databases, embedded guidelines for clinical practitioners, document imaging and telemedicine.
These areas are more controversial. Do doctors want to prescribe to computerised guidelines? This has been a major issue in the roll-out of NHS Direct, the telephone-based NHS advisory service, criticised for forcing trained nursing staff to answer queries through the use of strict, computer-based guidelines, rather than using their own professional expertise.
And the growing number of telemedicine projects in the UK has highlighted problems in implementing IT-enabled medical systems that have nothing to do with technology and everything to do with changes in relationships between healthcare professionals and those who use their services. Almost every doctor is now familiar with patients who have downloaded information on their condition, or that of their family, from the Internet.
Dr Ricky Richardson, a paediatrician who chairs the UK Telemedicine Association, believes we are now seeing a fundamental shift in attitudes towards health services. "Physicians will have to become more like a guardian or a shop assistant for different health products and services," he says.
That message is not welcome to many expensively trained healthcare professionals. But others believe technology can underpin and support aims of all workers.
"We are harnessing technology to help the community," says Diann Martin, vice president of home care and hospice nursing at the University of Chicago Hospital. "We are doing things for patients at home now that had to be done in hospital five or six years ago. People over 85 need affordable healthcare."
Ealing's NHS Trust online booking system
One of the biggest time-wasters in the NHS administrative system is the way GPs book appointments for patients with hospital consultants and specialists. Typically, a GP has to write to the consultant, wait for them to set a date and then notify the patient. This process can take two weeks. Worse, the patient is not involved, so they may be sent an appointment for an inconvenient time or date. This accounts for the high number of no-shows.
Ealing NHS Trust is tackling the problem by putting its outpatient appointment system online. Every year, 154,000 outpatient appointments are scheduled, but almost 18% of patients don't turn up. Ealing has installed software from McKesson HBOC to enable GPs to book appointments online, before patients leave the surgery, cutting the whole process to under five minutes. GPs will access the system via NHSnet, so they don't have to load software on their own PCs. Once logged into the system, the GP runs through a series of questions appropriate to the patient referral, intended to cut down on inappropriate referrals and ensure the patient sees the right specialist.
Initially, the system is being trialled by six GPs in the Ealing area. Eventually, it will run to more than 200 GPs. "It will cut down inappropriate referrals, and give patients a better quality of service," says John Inwood, assistant project manager at Ealing NHS Trust.
Pioneering with Wap and PDAs
Mobile phones have already brought advantages to workers in the health sector, especially for two sets of staff: hospital-based clinicians, who need to be reached and updated on cases quickly, and remote workers, like district nurses, who need to keep track of home visits.
So far, mobiles have been used for voice calls or short text messages, which both have limitations. Technology managers across the health service are evaluating data communications, based on the wireless application protocol (Wap), to see if this would help remote workers to dial in to centrally-held data, rather than loading up information onto portable devices and then feeding changes into a central system. Potentially, there's a big market for Wap phones in the health sector and they are becoming more available. In July, high street mobile phone specialist Carphone Warehouse offered health workers free Wap-enabled mobile phones via a tie-up with online health service provider Health-Media.Net. More than 100,000 healthcare staff expressed interest, though Health-Media.Net has not said how many phones were issued.
Real Wap apps are held up in the health sector, just as in the consumer market, by problems of speed and ease-of-use. Mobile phone screens and keyboards are too small to use easily and data can only be transmitted slowly and expensively.
The answer, according to some suppliers, is putting Wap-based applications onto palmtops and personal digital assistants. Here, interest is shown right across the health sector. In Manchester, 300 district nurses were issued with Hewlett-Packard Jornada palmtops. Community care workers in Wakefield and Pontefract are also using mobile devices holding up to 3,000 patient records, using Microsoft's Pocket PC software.