From Nhs It Info
Research Challenges in Emergent e-Health Technologies (6 Jul 2001)
Department of Computer Science, Australian National University
Notes to accompany a Panel Session on 'Research Challenges in Emergent e-Health Technologies', with Joan Cooper (Chair), Carole Alcock, Lois Burgess and Tanya Castleman, at the IFIP TC8 Conference on 'Developing a dynamic, integrative, multi-disciplinary research agenda in E-Commerce / E-Business', Salzburg, 22-23 June 2001. . . The focus of this Panel Session was on information technologies applied to health care. In addition to the long-promised health care smart-card, current initiatives include electronic health records (EHR), and unique patient identifiers (UPI). These are expected to provide greater accessibility to personal health care data. They tend to assume the consolidation of data from many sources into a single unified scheme (whether the data is stored centrally, or stored in dispersed databases but within an integrative architecture), or at least into a smaller number of schemes than exists at present.
- the potential benefits of e-Health;
- the risks inherent in e-Health;
- possible solutions to the problems;
- e-consent; and
- research challenges." [Roger Clarke]
Implementing Information for Health: Even More Challenging Than Expected (10 Jun 2002)
School of Health Information Science, University of Victoria
By Prof. Dennis Protti - "Over the period 6th August to 19th October 2001, and at the invitation of the heads of the Information Policy Unit (IPU) of the Department of Health and the NHS Information Authority, I once again visited England to review the state of progress of Information for Health, taking account of the implications of the emerging changes within the UK health care system. Returning to the UK, it did not take me long to realise that the NHS was once again in the midst of a significant period of transition. It was evident, even to an outsider, that the United Kingdom has a Government which believes that the NHS has to be re-organised and made to be more equitable, accountable, and customer-focused. I sensed that it is a Government that is looking for obvious progress in reforming the public sector - spurred on in particular by negative media coverage about the NHS. In its recent policy document, Shifting the Balance of Power in the NHS (StBOP), the Government expresses its desire to devolve power and decision-making down to the frontline, to decentralise, to provide patients with choice, to give local staff the resources and the freedoms to innovate, develop and improve local services. This desire pervades the changes I observed and sets the tone for my report - these are fascinating, if somewhat daunting, times for the NHS. . ."
"There's no more pressing priority for the Government than improving the NHS. If possible, dramatically - and comfortably before the next election. It has less than three years. The money is available; although increased pay may absorb more than had been expected. How best to spend what is left? Surely to improve the lot of the patient? Apparently not. The Government has chosen a course that is likely to make it worse: sweeping and massively expensive changes to NHS computing systems. We are told it is "the IT challenge of the decade" and "a Herculean task". Why don't people learn? Why are big IT projects seen as a badge of virility - a sign that we really mean business? They nearly always cause trouble: the bigger the change the bigger the trouble, especially in the public sector. Difficulties with this Government's earlier IT plans for the NHS (this is the third) demonstrate that the risk is especially great for such a uniquely complex organisation - employing 1.3 million people with over 50 million potential patients. Ambitious IT changes rarely deliver what is promised and commonly cause serious inconvenience for those they are intended to benefit: in this case, the patients. Surely anyone who wishes the NHS well would be striving to introduce the minimum necessary IT change, the smallest possible challenge? . . ."
Why general practitioners use computers and hospital doctors do not (2002)
- Almost all British general practitioners use computers in their consulting rooms, but most hospital doctors do not
- Over 30 years, leaders of the general practitioner profession have worked with government to provide incentives for computerising practices and to remove barriers
- In hospitals computing was treated as a management overhead, and doctors had no incentives to become involved
- The success of the government's plans for "joined up," computer based health services depends on providing appropriate incentives to hospital doctors
- General practice computerisation has been a success, but what works in a GP surgery does not readily scale up to work in a hospital
- Computer based patient records have a more diverse range of uses in hospitals than in general practice, and simple unidimensional classification schemes such as the original Read codes cannot cope
- In hospitals many different computer systems need to be linked together, requiring common interoperability standards
- Protection of privacy is a much greater problem in hospitals
- The number of potential users in hospitals makes substantial demands on hardware and networks"
Green Book, Appraisal and evaluation in central government (16 Jan 2003)
"Information is needed for a market to operate efficiently. Buyers need to know the quality of the good or service to judge the value of the benefit it can provide. Sellers, lenders and investors need to know the reliability of a buyer, borrower or entrepreneur. This information must be available fully to both sides of the market, and where it is not, market failure may result. This is known as 'asymmetry of information' and can arise in situations where, for example, sellers have information that buyers don't (or vice versa) about some aspect of product or service quality. Information asymmetry can restrict the quality of the good traded, resulting in 'adverse selection'. Another possible situation is where a contract or relationship places incentives upon one party to take (or not take) unobservable steps that are prejudicial to another party. This is known as 'moral hazard', an example of which is the tendency of people with insurance to reduce the care they take to avoid or reduce insured losses." [The CfH team admitted at our meeting in April that there was a considerable amount that they did not know about the technical details of the systems they were buying. Indeed, the whole nature of output-based specification (OBS) seems to ensure information asymmetry and moral hazard as defined below.]
HIPAA Compliance and Smart Cards: Solutions to Privacy and Security Requirements (Sep 2003)
Smart Card Alliance
"This white paper was developed by the Smart Card Alliance to describe how smart cards can be used to meet HIPAA Security Rule and Privacy Rule requirements. Designed as an educational overview for decision makers, it summarizes the HIPAA privacy and security requirements, provides an overview on how smart cards work, describes how smart cards can be used to support HIPAA compliance and implement other health care applications, and outlines key implementation success factors. The white paper also includes profiles of smart health card implementations including the University of Pittsburgh Medical Center, Mississippi Baptist Health Systems, and the French, German and Taiwanese health cards."
"This week's announcement of the NHS on line patient booking system reminded me of a unique preview I received a few months ago, courtesy of Virgin Trains West Coast Line. I had requested and received an Oxenholme-Euston ticket for the first-class quiet coach, hoping to work on the way. But Virgin forgot to include the coach and instead, I was treated to an episode in the life of government.uk from the man across the table, sorry desk, from me. Small, balding and in his 40s, Richard G.* appeared to be an IT manager attached to the Department of Health probably, I thought, one of that twilight army of government special advisors. Non-stop high-volume input into his mobile and dictaphone demonstrated ad nauseam he was not one to use plain English when a managerial clichÃ© was to hand. . ."
"According to the popular notion of how medicine will be practiced in the future, omnipresent, intelligent systems will acquire and store all available information about what is going on in the healthcare environment. . . The gap between our expectations and what is available today is large and may not diminish any time soon. There are reasons for this gap that can be analyzed and debated at length but that does not alter the fact that the gap exists and the gap is our problem. For years now, our unrealistic expectations have stood in the way of taking practical steps to achieve a way of doing business in the new facility that does not produce paper that required long-term storage. There are a variety of pragmatic solutions that will address this requirement in isolation and a smaller number that can also deliver some of the computerized functions that physicians associate with a computerized patient record." [See Appendix 9]
New NHS IT (Feb 2004)
Parliamentary Office of Science and Technology
"The Government has recently signed contracts for a £6 billion modernisation of NHS computer systems in England. This national IT programme has four main parts: electronic patient records, electronic appointment bookings and electronic transmission of prescriptions, along with an upgraded NHS broadband network. However, it involves both managing a large IT procurement and imposing change on the highly devolved NHS. This POSTnote outlines the main projects in the national programme and their potential benefits, then examines key concerns, such as confidentiality, funding and involving clinicians."
Achieving Electronic Connectivity in Healthcare (Jul 2004)
Connecting for Health (US)
"A Preliminary Roadmap from the Nation's Public and Private-Sector Healthcare Leaders . . . Our recommendations are designed to be practical. We are proposing manageable actions to be taken over the realistic time frame of the next one to three years. It is not possible or even desirable to dramatically transform the healthcare system through a sudden "big bang," whether brought about by public or private efforts. We believe that the existing system needs to be improved and built upon, and that the effect of carefully planned incremental steps can be equally transformational and more likely to succeed over the long run. Our realistic recommendations are not intended to discourage bolder actions now or in the future, but they allow a large proportion of stakeholders to make measurable progress now. In fact, because of their strategic nature, they set the stage for bolder actions to follow. . ."
Current EHR Developments: an Australian and International Perspective (1 Sep 2004)
Health Care and Informatics Review (New Zealand)
"Abstract: The idea of electronic health records (EHRs) began at least 40 years ago but the first implementations did not really begin until the 1980s and, with the exception of a few countries in Europe, the use of EHRs is still very low in most countries. This is beginning to change rapidly, however, and the emergence of purpose-built shared-EHR systems to underpin multi-disciplinary integrated shared care in a number of countries is adding a whole new dimension to the field. Australia is in the early stages of developing its national "HealthConnect" shared-EHR network and similar projects are also underway in several other countries such as Brazil, Canada and England. The US does not have any national EHR projects as yet but there is a groundswell of interest and initiatives in relation to the EHR in the US which could foreshadow rapid progress there in the next few years. Lack of interoperability between EHR systems has been a major barrier to EHR deployment but the emergence of the openEHR model, the HL7 Clinical Document Architecture and archetypes has provided a significant stimulus to the development of interoperability and other necessary EHR standards within major international standards organisations such as ISO, CEN and HL7. There is a long way to go but there are encouraging signs that stakeholders are beginning to recognise that the very future of health systems depends on more efficient and effective information management. The EHR is arguably the most important foundation component in this pursuit."
The Spine, an English national programme (25 Mar 2005)
Ringholm White Paper
"The English Spine (the national IT infrastructure for healthcare) will provide a commonly accessible patient based resource, making information from multiple sources available to all those with a legitimate care relationship to the patient. This includes all health professionals whether they work in a hospital, in primary care or in community service. The architecture of the Spine is based on a centralized partial care record, supported by directory services and HL7 version 3 messaging."
Will NPfIT Suceed? (April 2005)
(Chapter 15 of Sean Brennan's book: "The NHS IT Project: The Biggest Computer Programme in the World... Ever!")
Radcliffe Publishing Ltd
". . . So we come to the £30 billion question. Will it work? If NPfIT is about getting the best deal for IT infrastructure for the NHS then, yes, it will be a success. The NHS was a huge spender on IT before the national programme started. Now it gets more, it gets it delivered as a service, and it gets it all at a very keen price. It will get several hundred PAS systems, clinical systems, and all sorts of associated applications delivered down a pipe to the bedside. So let's try a tougher question. Will all the software and applications work in the way that they are meant to work? Will the spine integrate seamlessly with systems in the five clusters? Will the security and confidentiality work to everyone's satisfaction? The answer to this question is probably 'eventually'. So long as the momentum is maintained and the funding is sustained, then one day it will all come together. There is, after all, very little in the programme that is totally conceptually new. But it may all take a lot longer than the NHS expects. New software always seems to take longer to design, build and test than anyone expects. This is an ambitious programme, and there are many obstacles in the path. The main software developers have a lot of code to write. I would expect to see slippages, renegotiations of deadlines, a general downplaying of expectations, and a long hard slog by the service providers, the software developers, and the NHS alike before it all starts to come together. There will certainly be scare stories along the way. The press will gather around every hint of failure and will predict catastrophe. But in the end, this isn't rocket science. It will work because it has to work. The day will come when the systems are in and the project will be signed off. Of course, by then there will be new challenges, new technologies, new obstacles. But that will be tomorrow's problem. Another rainbow. But perhaps even this wasn't the question that you wanted answering. If NPfIT is about changing the way healthcare is delivered, then there is a third answer to the question 'will NPfIT succeed?' It will struggle. 'That's not what NPfIT is about,' I can hear from some readers, and true, the programme's remit isn't to change the world, just to deliver as a service to the NHS, an IT infrastructure for the NHS to use as it chooses. The programme is branded and perceived as a technology initiative. It is a technology initiative. Yet this perception could be its undoing. People might assume it to be non-clinical. It could become another big PAS project. And that would be a shame. The deals that have been negotiated by the national programme are there to ensure that the NHS has access to cutting-edge technology after years of 'playing around' with IT. But will clinicians see the opportunities to change the way the NHS is delivered? Will this change be an opportunity to them or a threat? The key purpose of the NHS is to deliver effective clinical care. Technology will offer alternative ways of delivering that care so NPfIT is, whether it likes it or not, central to the modernisation of the delivery of clinical care. This is not just about having an electronic record. It is far deeper and grander than that. It is about supporting clinical care with IT, and when you support clinical care with IT, you can then use that technology to influence how that care is delivered. . ."
Transformational Government: Enabled by Technology (Nov 2005)
Cabinet Office Report
". . . Information Assurance: despite the difficulties of a fast moving and hostile world, underpinning IT systems must be secure and convenient for those intended to use them. The Government will further develop its risk management model to provide guidance on this, approved by the Central Sponsor for Information Assurance. And it will develop a simple, tiered architecture for its own networks to support this model in practice, with an updated application of the protective marking scheme for electronically held information. Government will also play its part to promote public confidence by leading a public/private campaign on internet safety and by a new scheme to deliver a wider availability of assured products and services. . . Identity Management: government will create an holistic approach to identity management, based on a suite of identity management solutions that enable the public and private sectors to manage risk and provide cost-effective services trusted by customers and stakeholders. These will rationalise electronic gateways and citizen and business record numbers. They will converge towards biometric identity cards and the National Identity Register. This approach will also consider the practical and legal issues of making wider use of the national insurance number to index citizen records as a transition path towards an identity card."
OpenEHR (10 Feb 2006)
"The openEHR Foundation is a non-profit charity based in the United Kingdom at University College London. It is now a community of more than 600 people working on an open specification for a shared electronic health record. openEHR utilises a two level modelling approach developed in Australia. This approach means that the rules about how to represent clinical information in an openEHR record are captured in Archetypeswhich can be shared and evolve, while the parts from which these models are constructed are unchanging and in the reference model. The result is that software can be built on the rich and stable reference model, and the changing and evolving clinical concepts can be managed in a knowledge environment - called the archetype repository. Archetypes carry with them rules that check the quality of the data and they can be used at data entry to ensure data quality. The display information is carried separately enabling the same information to be displayed in a different manner for different purposes. This makes the approach very flexible, so that personal health records can be displayed in a manner suitable for individual patients, sort of like skins for software programs. The benefits of this approach is that the richness of clinical concepts can grow with time, without needing to change the software at a fundamental level. Also, openEHR records can be carried on a USB stick or communicated in any way necessary. Australia is the first country to take on openEHR in larger scale situations, with growing interest in other countries such as Sweden, India and Slovenia."
Review of Shared Electronic Health Record Standards (20 Feb 2006)
National E-Health Transition Authority (Australia)
An official review of coding standards for supporting the sharing of electronic health records - covering openEHR, EN13606, and various version of HL7, whose recommendations are that the European EN13606 standard on EHR Communication should be used as the basis for specifying the content and logica structure of shared EHR information, and as a short term measure, the use of HL7v2 as the means of specifying the syntax and representation of such information. HL7v3 was discounted as "this would be more complex, costly and take considerably longer than the recommended approach".
System Design Or Social Change (6 Apr 2006)
Parliamentary IT Committee (PITCOM) on the subject of Public Sector 'IT' procurement
Submission by Malcolm Mills: ". . . I suggest three things. Immediately, to increase the success rate and restore confidence, I would simplify, de-risk and specify a more evolutionary set of requirements for endeavours of this kind. I would then increase their delivery time-scales to be more in keeping with the much longer timeframes we know from experience are associated with achieving successful social change. In the medium term, I would do two things: Recognising that the major risks, and by far the greater costs, lie with the addressing people issues, and not technology ones, HM Treasury should commission new "Green Book" appraisal guidelines for scrutinising the budgeting and planning of socio-technical endeavours during the Gateway decision-making process. And finally, faced with clear evidence of an acute shortage of interdisciplinary skills and competences in Government and Industry to design and manage the range of socio-technical systems in the public programme, a task force should be established to examine how the Nation might produce a sufficient number of competent and skilled people able to lead, develop, and then support, such critical endeavours. . ."
Guidance for NHS Foundation Trusts on Co-operating with the National Programme for Information Technology (12 April 2006)
Monitor, Independent Regulator of NHS Trusts
". . . Condition 20 of the terms of authorisation for all NHS foundation trusts states that: "The Trust shall participate in the national programme for information technology, in accordance with any guidance issued by Monitor." This note summarises how Monitor will interpret the requirement on NHS foundation trusts to participate in The National Programme for Information Technology (NPfIT) as administered by Connecting for Health (CfH) and constitutes Monitor's guidance under Condition 20. Monitor recently published Risk Evaluation for Investment Decisions by NHS Foundation Trusts 1 which relates to high risk investments as defined by either size or risk. Each investment necessary under NPfIT should be evaluated against these definitions to confirm their status. In any event the frameworks in the guidance are good practice which should be applied to any investment decision undertaken, including those within NPfIT. . ."
NHS IT chief meets criticism head-on (25 May 2006)
"When Tony Blair addressed the annual CBI dinner last week he discussed the challenges of modernisation. He also cited the £6bn, 10-year National Programme for NHS IT (NPfIT). "The NHS IT strategy is a large and complex programme, but it is having a real impact," said the Prime Minister. Blair's endorsement runs contrary to the condemnation that has dogged the programme in recent months. A group of academics has described the project as "fundamentally flawed' and there have been continued criticisms of delivery delays, changing specifications, disagreements with clinicians, and financial problems for suppliers. Worse is yet to come. A National Audit Office report is due, and NHS IT director general Richard Granger faces a tough grilling by the Public Accounts Committee next month. But Granger, while acknowledging there have been delays and variable supplier performance, says such a revolutionary programme was never going to be easy to implement. "We are breaking new ground: some things go well, some things are difficult - and those that are difficult get a disproportionate amount of attention," Granger told Computing. "People seem to forget that these systems are disruptive and introducing them is disruptive, but we have to hold our nerve," he said. . .?
'Computer says no' to Mr Blair's botched £20bn NHS upgrade (4 Jun 2006)
". . . It was born in a "Wouldn't it be great?" moment, a year after Tony Blair arrived in Downing Street. In a speech about the NHS, the Prime Minister touched on what sounded a simple, laudable vision: using computers to create a more efficient, safer, patient-friendly health service. "If I live in Bradford and fall ill in Birmingham, I want the NHS to be able to treat me," Mr Blair said in 1998. . . The plan would link more than 30,000 GPs with 300 hospitals. "Up to 600 million pieces of paper a year" would be saved, Mr Blair promised. Patients' notes would be available in any hospital at the click of a mouse, and GPs would be able to book hospital appointments over the internet ("choose and book"). The Prime Minister even joked about making GPs' handwriting "legible for the first time in history". Four years later, the joke is on Mr Blair, and the taxpayer. The "Connecting for Health" project is two years behind schedule and more than three times over its initial £6.2 billion budget. Lord Warner, the health minister, revealed this week that the real cost of the programme would approach £20 billion by 2010, its revised delivery date. A report by the National Audit Office (NAO) is expected to be damning, suggesting that corners were cut so that political deadlines could be met. More than £11.75 million of taxpayers' money has been lavished on consultants, including Ernst & Young, Price Waterhouse Coopers, PA Consulting, Cap Gemini and IBM. Yet the glitzy, "joined-up" NHS remains a low-tech hotch-potch. Doctors are largely unimpressed. Dr Richard Vautrey, a GP in Leeds and spokesman for the British Medical Association on IT, has struggled for months, for example, to get "choose and book" working. . . With its 950-strong staff and an annual wage bill of about £50million, Connecting for Health does not lack resources. Still, it has become the latest in a series of public sector IT fiascos which include the Passport Office, Air Traffic Control, the Child Support Agency and the Inland Revenue. . ."
Granger: bricks of the digital NHS coming together (16 Jun 2006)
"The pace of delivery of new IT systems to the hospital sector has been "disappointing", says NHS IT director general Richard Granger NHS IT director but he says the bricks that will build a digital NHS are slowly coming together. In an interview given to E-Health Insider in the run-up to the publication of the NAO report into the delayed NHS National Programme for IT, he acknowledged that some things had gone well and others less well. "We've got a lot of deployment done and we've got a lot of things that are troublesome out there." He added: "I'm not sure we've got to the bottom of some of the engineering challenges." Granger says delivery to hospitals had been particularly difficult "The difficulties that independent software vendors have had in that sector are a work in progress". . . Asked whether the NHS CRS remained deliverable Granger told EHI that the IT strategy he was brought in to procure against and implement had already been set by the time he came into post. Granger named individuals including Dr Anthony Nowlan of the old NHS Information Authority (NHSIA), Jeremy Thorp and Professor Peter Hutton as being parents of the strategy and specification procured against. "Dr Anthony Nowlan spent the early part of this decade in the IA undertaking consultation about the EPR [electronic patient record] and feeding in details of the consent model and details of that record to 21st Century IT, and then to an output specification produced by Jeremy Thorp."
Information Governance in NHS's NPfIT: A case for Policy Specification (2006)
Moritz Y. Becker, Microsoft Research (To appear in International Journal of Medical Informatics, 2006.)
". . . The NHS's National Programme for IT (NPfIT) in the UK with its proposed nation-wide online health record service poses serious technical challenges, especially with regard to access control and patient confidentiality. The complexity of the confidentiality requirements and their constantly evolving nature (due to changes in law, guidelines and ethical consensus) make traditional technologies such as role-based access control unsuitable. Furthermore, a more formal approach is also needed for debating about and communicating on information governance, as natural-language descriptions of security policies are inherently ambiguous and incomplete. Our main goal is to convince the reader of the strong benefits of employing formal policy specification in nation-wide electronic health record (EHR) projects. . ."
Extracts from the book by David Craig, provided here with the author's and publisher's permission.
NHS IT systems crisis: the story so far (30 Aug 2006)
Computer Business Review
"The NHS's Connecting for Health plan to update and link up health service systems have hit the headlines in recent weeks thanks to reported problems with key software supplier iSoft, and criticisms of the project's management and cost. CBR has been tracking the project since its creation, and in this article has brought together the story so far, beginning with the handing out of contracts in late 2003. . ."
eHealth is Worth it (Sep 2006)
European Commission, Directorate General Information Society and Media, ICT for Health Unit
"An assessment of the economic benefits of implemented eHealth solutions at ten European sites."
Safer IT in a safer NHS: account of a partnership (Sep 2006)
British Journal of Health Care
"Following a high-level assessment of patient-safety management in England's National Programme for IT, the National Patient Safety Agency and NHS Connecting for Health have been working together to start minimising ICT-related hazards in the NHS. Dr Maureen Baker, Ian Harrison and Professor Sir Muir Gray, who are leading the execution of this new initiative, describe its aims, achievements and plans.
Abstract: The use of ICT in healthcare has considerable potential to support clinicians in practising more safely, but also has the potential to affect patient care adversely if there are faults in the systems or if implementation is flawed. This article describes the partnership between NHS Connecting for Health, the agency delivering the National Programme for IT in the NHS in England, and the National Patient Safety Agency (NPSA) in working for safer systems for the NHS and safer care for patients."
Dying for Data (Oct 2006)
"A comprehensive system of electronic medical records promises to save lives and cut health care costs - but how do you build one?" (Robert N. Charette)
'Gung-ho' attitude scuppers public-sector IT projects (2 Oct 2006)
"Government IT heads - 'gung-ho' and reckless attitudes to risk is wasting millions of taxpayer money on over-complex, poorly tested systems, according to a think-tank study. Contrary to the stereotype, many public-sector managers have a "reckless streak" and are dazzled by the potential of the technology, according to the Where next for transformational government? report by The Work Foundation, (September 2006)"
IT and Modernisation (9 Oct 2006)
"This New Statesman round table discussion, sponsored by Atos Origin, debated issues around IT and how it affects the modernisation of society and, in turn, how society's attitudes affect the technology that seeks to make our lives easier. Public perception of IT projects as successes or failures can have a dramatic impact on those working in the industry, and which projects they take on. Projects that take several years to realise can change considerably from the initial scope. Comparisons between public and private sectors can be misleading in such a young industry."
Problems abound for Kaiser e-health records management system (13 Nov 2006)
An internal report details hundreds of technical issues and outages. An electronic health records management system being rolled out by Kaiser Foundation Health Plan/Hospitals has been nothing short of an IT project gone awry, according to sources at the company and an internal report detailing problems with the HealthConnect system. Questions about the project arose last week at about the same time Cliff Dodd, the company's CIO, resigned. Dodd stepped down last Monday after another Kaiser employee, Justen Deal, sent a memo to every company worker warning of technological and financial repercussions related to the rollout of the nearly $4 billion system from Epic Systems Corp. . ."
The Common Framework: Overview and Principles (5 Dec 2006)
[US] Connecting for Health
"The members of Connecting for Health passionately believe that the private and secure exchange of health information nationwide is essential to the well-being of patients and those who care for them. It has been nearly two years since we published the "Roadmap" report - Achieving Electronic Connectivity in Healthcare: A Preliminary Roadmap from the Nation's Public and Private Sector Healthcare Leaders. . . But we were determined not to stop at words. Within the last year we have built a working prototype of the Roadmap model - together we have learned how three very different communities, with different hardware, software, and organizational structures, can in fact share information in a private and secure way over the Internet using a Common Framework. Our partners in Mendocino County, CA, Indianapolis, and Boston worked closely with a Connecting for Health Technical Subcommittee and Policy Subcommittee made up of more than 75 people drawn from the Connecting for Health Steering Group plus other recognized experts. The Subcommittees helped to shape and test the prototype, documented the lessons of its implementation, and drafted a first iteration of the Common Framework, which we are releasing today. Although it is just a start, we are confident that it will evolve to meet the needs of a varied and fragmented healthcare system. We invite others to use, adapt, and help us to improve the Common Framework. As Connecting for Health has been constructing a prototype and Common Framework, several complementary developments have taken place, building on the ongoing efforts of local communities: new communities for health information exchange are forming with great speed, Federal and State governments have put an unprecedented spotlight on the importance of health information technology, the Department of Health and Human Services and the Office of the National Coordinator have provided their leadership and millions of dollars toward a connected healthcare system, and Congress has sponsored many initiatives - all designed to further health information sharing. . .
Connecting for Health's Policy Principles
- Openness and Transparency: There should be a general policy of openness about developments, practices, and policies with respect to personal data. . .
- Purpose Specification and Minimization: The purposes for which personal data are collected should be specified at the time of collection, and the subsequent use should be limited to those purposes . . .
- Collection Limitation: Personal health information should only be collected for specified purposes . . .
- Use Limitation: Personal data should not be disclosed, made available, or otherwise used for purposes other than those specified.
- Individual Participation and Control: Individuals should control access to their personal information . . .
- Data Integrity and Quality All personal data collected should be relevant to the purposes for which they are to be used and should be accurate, complete, and current.
- Security Safeguards and Controls: Personal data should be protected by reasonable security safeguards . . .
- Accountability and Oversight: Entities in control of personal health data must be held accountable for implementing these information practices.
- Remedies: Legal and financial remedies must exist to address any security breaches or privacy violations.
Connecting for Health's Technology Principles
- Make it "Thin": . . . It is desirable to leave to the local systems those things best handled locally, while specifying at a national level those things required as universal in order to allow for exchange among subordinate networks.
- Avoid "Rip and Replace": Any proposed model for health information exchange must take into account the current structure of the healthcare system. . .
- Separate Applications from the Network: . . . The network should be designed to support any and all useful types of applications, and applications should be designed to take data in from the network in standard formats. . .
- Decentralization: Data stay where they are. . . leaves judgments about who should and should not see patient data in the hands of the patient and the physicians and institutions that are directly involved with his or her care.
- Federation: . . . Formal federation with clear agreements builds trust that is essential to the exchange of health information.
- Flexibility: Any hardware or software can be used for health information exchange as long as it conforms to a Common Framework of essential requirements. . . The network must be able to scale and evolve over time.
- Privacy and Security: All health information exchange, including in support of the delivery of care and the conduct of research and public health reporting, must be conducted in an environment of trust, based upon conformance with appropriate requirements for patient privacy, security, confidentiality, integrity, audit, and informed consent.
- Accuracy: Accuracy in identifying both a patient and his or her records with little tolerance for error is an essential element of health information exchange. . .
Transcript of BBC Radio 4's 'Any Questions' (22 Dec 2006)
One of the questions discussed by the panel (Michael Portillo, Oona King, Richard Lambert, Johann Hari) was "Do the government's intended national databases in the NHS, the national ID scheme, the children's database and so on threaten privacy and liberty and are they solutions in search of problems?".
Digital healthcare: the impact of information and communication technologies on healthcare (Dec 2006)
The Royal Society
From the Recommendations: "We recommend that the Government health Departments and their associated national IT programmes adopt an iterative and incremental approach in the design, implementation and evaluation when introducing new healthcare ICTs. We make several additional recommendations to support such an incremental approach: (a) We recommend that healthcare professionals and their professional bodies seek to be involved in the design, implementation and evaluation of healthcare ICTs. (b) We recommend that healthcare managers ensure that sufficient time is made available for healthcare professionals to contribute effectively at all stages of design, implementation and evaluation of healthcare ICTs. . . (f) We recommend that the national IT programmes ensure that all stages of the development are undertaken within standards to ensure interoperability and that evaluation is built into development."
Patient Administration Systems (Dec 2006)
Executive Summary: "Patient administration systems, managing and recording patient identification, admissions, bookings and discharge, form the foundation of any clinical IT system and the platform upon which to build electronic patient records. PAS systems are vital to the effective operation and management of hospitals and community services, generating information such as clinic lists and activity reports, enabling the hospital to record activity, monitor throughput against contracts and report to its service commissioners and performance against key targets. Delivering new standardised PAS systems has unexpectedly become a central objective of the £12bn NHS Connecting for Health IT upgrade programme in its first three years as a precursor to the Care Record Service (CRS). Mounting delays and recent switches in prime contractors and software suppliers, however, mean that the PAS market is rapidly evolving, becoming more porous with new opportunities arising. Critically, the role of "existing suppliers" and importance of "interim systems" is growing, creating new opportunities for suppliers and new options for NHS trust customers. In the first of a new series of health IT market perspectives, E-Health Insider examines the key features of the NHS PAS market in England."
Account by Geoff Sampson of an American online patient-information service.
The Information Commissioner's view of NHS Electronic Care Records (18 Jan 2007)
The Information Commissioner's Office
"Conclusion: The Commissioner has been consulted by NHS Connecting for Health about their plans for electronic care records and can see the potential benefits these may bring. However the NHS must continue to comply with the Data Protection Act 1998 and this is vital to guarantee that public confidence is maintained. The Commissioner will be monitoring the implementation and operation of the new NHS Care Records Service to ensure patients are provided with adequate information and choices and that their health data is maintained in a safe and secure way. As part of this he will continue to engage with NHS Connecting for Health on a number of issues, in particular those relating to the accuracy of the information to be uploaded, the way people are informed about the changes and the systems in place to allow people to access their own information."
Transformational Government: Annual Report 2006 (Jan 2007)
Chief Information Officer Council, Cabinet Office
The National Programme for IT is a large, complex programme, and the NHS is one of the world's largest organisations, itself undergoing radical change to deliver better healthcare for people. A key challenge is to introduce modern IT and the business changes necessary to exploit it fully without impacting the safe delivery of care. In a 10-year programme of this size, scale and complexity, it is to be expected that there will be issues and difficulties; NHS Connecting for Health has been open about this. The National Programme for IT has set itself ambitious and challenging targets to deliver systems to provide defined benefits. It believes it is better to delay implementation of a system to get it right for patients and clinicians, rather than to deploy it rapidly and get it wrong. The software to support key national elements of the programme has been delivered on time and to budget, and parts of the national systems have gone live as planned. There have been delays to the clinical record system due to the complexity of developing software that interacts with a large number of existing systems, and also due to the need to get doctors to agree on the contents of electronic health records. The cost of these delays is being met by ICT suppliers, not the taxpayer. Operating in this environment, and on this scale, inevitably presents challenges that the programme has overcome through innovation. These challenges include the following:
- Positively engaging clinicians in the business change necessary to deliver the benefits of the new technology to patients and staff, ensuring that systems deliver their full potential.
- The capacity and capability of suppliers within an innovative but tight contracting and performance environment.
- The capacity and capability of project and programme management within the NHS.
- Delivering such a major system at a time of great structural business change for the NHS, including the creation of independent trusts.
- Positively engaging all stakeholders to ensure that all concerns and criticisms are addressed.
IT in the NHS: National or Local Design (Jan 2007)
The Bayswater Institute [Powerpoint lecture (with notes) by Ken Eason.]
". . . As sociotechnical systems specialists we might argue that it is not a good principle to attempt a centralised and standardised programme of IT developments on the massive scale we have in NPfIT. The way that the diversity of local requirements across the NHS Trusts has become manifest as the implementation programme has proceeded is ample demonstration that "one size cannot fit all" in such a complex system. What is a bit more hidden at the moment is what is happening when these applications are implemented and are used by local healthcare teams. What is becoming apparent is that varied local ways of responding to the systems is inevitable. Unfortunately, whilst there is quite a lot of potential for local sociotechnical systems design, the process of implementation does not encourage thoughtful, evolutionary work with the user community. . ."
Community Pharmacist Access to Patient Care Records (Jan 2007)
National Pharmacy Association
"The Government's vision of integrated health care by 2010 is exciting and ambitious. To help realise this vision, a major Information Technology programme is underway to revolutionise communication across the NHS. Among other innovations, careproviders in all settings will have electronic access to a patient's medical record at the point of care. This position paper makes the NPA case for both read and write access to Care Records for community pharmacists. Pharmacists need access to Patient Care Records for a number of reasons: 1. To benefit patients; 2. To prevent harm to patients; 3. To benefit other care professionals; 4. To carry out their responsibilities under the new contract; 5. To benefit pharmacists themselves."
NPfIT - a personal view, by Robin Guenier (6 Feb 2007)
[Presentation] given at the 4th Annual Successful Implementation of NPfIT Conference (London, 6-7 Feb 2007).
". . . NPfIT's success is at risk - even if technically sound
Proposal - national level
Appoint an SRO with full-time responsibility and four immediate priorities:
- A thorough assessment of time & cost v. objectives
- A short, independent, focused technical review: is national integration practicable?
- Appoint local SROs
- Advice on project status to all end users
And two follow-on priorities:
- Develop and publish a full business case as defined above
- Start a detailed, interactive engagement programme with all end users . . ."
Lost? - by Andrew Rollerson (6 Feb 2007)
Presentation given at the 4th Annual Successful Implementation of NPfIT Conference (London, 6-7 Feb 2007).
"We have become obsessed by the alligators nearest the boat. Short term challenges have distracted us from the goal. The business goalposts have moved, but not the contractual ones. The Programme has not been structured for a dynamic environment. The challenges of scale and scaling have still not been faced. To solve the challenges faced by the Programme, our perspective has to be right, and we need to view the Programme itself from the proper perspective. The Programme needs committed partners who have staying power. There are never any road signs to your destination when you are heading directly away from it. . ."
Kaiser has aches, pains going digital (15 Feb 2007)
Los Angeles Times
"Patients' welfare is at stake in the electronic effort, experts say. Kaiser Permanente's $4-billion effort to computerize the medical records of its 8.6 million members has encountered repeated technical problems, leading to potentially dangerous incidents such as patients listed in the wrong beds, according to Kaiser documents and current and former employees. At times, doctors and medical staff at the nation's largest nonprofit health maintenance organization haven't had access to crucial patient information, and system outages have led to delays in emergency room care, the documents show. Other problems have included malfunctioning bedside scanners meant to ensure that patients receive the correct medication, according to Kaiser staff. Concerns about Kaiser's effort, called Health Connect, recently led the California Department of Managed Health Care to request information about the project, a first step before a possible formal investigation. The HMO's problems come as it plans to expand the computerized system over the next two years to nearly three dozen more hospitals - most in California - where the sickest patients are treated and ensuring patient safety is most difficult. Currently, the system is fully rolled out only in two hospitals, Baldwin Park Medical Center and South Sacramento Medical Center. Kaiser's effort, one of the largest and most ambitious electronic medical records projects in the country, is seen as a possible national model. With evidence suggesting that digitized recordkeeping can lower health costs and save lives, President Bush is pushing for every American to have an electronic medical record by 2014. But the glitches illustrate the difficulties a massive healthcare provider might encounter trying to implement a complex computerized system. . ."
Speaking Truth to Power (Mar 2007)
"Whenever I conduct an architectural assessment - well, really, I try to apply the following principle in all my dealings - I endeavor to speak truth to power: those with true power never fear the truth. That being said, sticking to that precept has gotten me kicked off at least two projects. In one case, I'd suggested to management that they simply cancel their project because it had a corrupt architecture and a dysfunctional process that were beyond repair. They eventually did cancel the project, but only after they had spent several more tens of millions of dollars of taxpayer money. In the other case, my recommendations were clearly contrary to the project manager's political aspirations, so my papers were buried and I was shuffled out the door. Rumor has it that this project was also later canceled, but not before the manager in question moved up the ladder, leaving the morass and the resulting blame to his successor. . ." [Grady Booch]
Implementing Snomed CT within national electronic record solutions (10 Apr 2007)
CHIRAD - the Centre for Health Informatics Research
"The experience and lessons learned from implementation projects have highlighted differences between suppliers, organisations and end users in what supporting SNOMED CT actually means, and the ability of existing solution architectures to support the advanced clinical documentation tool that SNOMED CT provides. In addition to the English Care record Service programme several other nations have "signed up" to utilising Snomed CT within their own national programmes, the most recent being France. One benefit of utilising Snomed CT is that if clinical data is input by clinicians at the point of care for clinical purposes then accuracy and detail should be improved for clinical care, and be available for downstream reporting and decision support and care pathway functions. There is therefore an expectation that SNOMED CT will support the implementation of payment schemes including Payment by Results (PbR) and the Quality and Outcomes Framework QoF) within the English NHS. SNOMED CT itself is only a part of the solution to addressing the requirements for effective electronic clinical records as a terminology and on its own does nothing unless it is both implemented and used. The implementation of SNOMED CT requires software applications that exploit its features to meet the real and perceived needs of users. The users of SNOMED CT are not restricted to end-users who enter or retrieve clinical information and experience SNOMED CT through a configured application that uses the terminology. Users also include those who design, commission and configure software for use in a particular clinical environment. SNOMED CT is not 'just another coding system' and its implementation will take some time and require significant development of the solutions. The adoption of SNOMED CT across and within nations will, by necessity, be incremental. In this extended implementation period, solution providers will need to support workarounds such as maintaining separate clinical terming and classification coding processes. Therefore, there will be a mixed population of systems and users that either can or cannot support SNOMED CT. This presents new problems regarding reporting, mixing, sharing and migrating of data. . . As systems push the boundaries of how SNOMED CT can be supported (in terms of simpler user interfaces and exploiting the encoded information to support clinical decision support), there will always be legacy data which is difficult to migrate to an unambiguous new form and to the required level of detail. Additionally, some users will be in advance of others, making data sharing using the right detail difficult. Therefore supporting SNOMED CT within solutions requires new databases, new processes and workflow, new reporting frameworks and ongoing maintenance. These must ensure that SNOMED CT can co-exist alongside other 'codes' until every patient record is fully SNOMED CT encoded. . .The key risk to SNOMED CT implementations is that financially and politically costly user implementation and technology strategies are developed and implemented without a clear vision for the end point."
Computer Weekly's campaign for NHS openness awarded (14 May 2007)
"Computer Weekly has won the publishing world's "Oscar" for campaigning journalism in recognition of our fight for an independent and published review of the NHS's £12.4bn National Programme for IT. It is the first time a magazine has won such an award twice for the same subject - in this case, the NPfIT. In 2004 the award citation said we had campaigned for a proper review of the NPfIT and had "battled against a strong climate of secrecy and suppression of dissent". That battle continues. There is still a minimalist approach to accountability - what the British Computer Society described as political pressure for officialdom to "deny problems and defend the indefensible". At the same time, the government wants everyone to applaud it for the achievements to come. But that would mean ignoring IT management in the health service, the BCS, leading academics, the NHS Confederation and several Royal Colleges. All have expressed profound misgivings about important elements of the programme. To this criticism the government has responded in the way we warned it would. In 2002, when the programme was launched, we accepted that it was announced with the best of intentions. But we questioned whether it was feasible and warned that the government would react to troubles by trying to head off perceptions of failure with statistics on the high numbers of transactions and registered system users. That is exactly what has happened. The government can stop our run of success in NHS campaigning. It can commission what the programme urgently needs: a genuinely independent review that is published in full and it can be open and honest about mistakes."
NHS IT: an open letter to Gordon Brown [By Robin Guenier] (26 Jun 2007)
"Dear Prime Minister, I don't suppose that the NHS National Programme for IT (NPfIT) is high on your list of priorities. I suggest it should be: you have an opportunity now to make some simple changes that could transform the programme, benefit the NHS and make a real difference to clinical care. Most informed people welcomed NPfIT when it was launched in June 2000, recognising the need for a comprehensive update of NHS IT systems. The project got fully started in April 2003 and, since then, around £2bn has been spent and much more committed. A lot has been achieved. Yet there are problems: key elements of the programme are years late, costs are escalating, suppliers are in trouble, users are disappointed and stakeholders feel neglected. The NHS insists all is well: a recent report for your predecessor is reported to have said, "Much of the programme is complete" In contrast, an April 2007 Public Accounts Committee report did not expect significant clinical benefit before 2013/14 when current contracts end. My purpose is not to discuss which view is correct but to recommend three actions that could transform NPfIT. First, I propose that a full-time "senior responsible owner" (SRO), as defined by the Office for Government Commerce, be appointed with unambiguous responsibility for the entire project. . . Secondly I propose that, as recommended in April by the Public Accounts Committee, the business case for NPfIT be subject to an independent review in the light of progress and experience so far. . . Finally, I propose that a major exercise be implemented to engage NHS staff, especially clinicians, with the programme. . ."
The Use of Personal Health Information in Medical Research (26 Jun 2007)
Medical Research Council
"This report presents the findings of a programme of research carried out among the general public by Ipsos MORI on behalf of the Medical Research Council (MRC). . . The main objective of the research was to identify public concerns and misconceptions surrounding the secondary use of personal health information for medical research. . . The two key pillars of anonymity and consent feature highly in the debate over what information should be available, to whom, and in what circumstances. These two themes are central to building trust. . . Results indicate that a majority of the general public feels that consent should always be sought. When given a variety of scenarios in which consent might not be essential, no more than a third of the public agrees with them. In Ipsos MORI's experience, this is quite low. Indeed just over one in five (21%) does not find any of the scenarios acceptable. The public is most likely to say consent is not important when the information is "not generally regarded as being sensitive" (35%). This is closely followed by when consent has already been given for use in a previous project (29%). These are two situations that also came out in the qualitative work as times when some (but not all) participants feel that consent is not always essential. Consistent with the findings coming out of the qualitative work, a majority (60%) agrees that they have a responsibility (as beneficiaries of medical research) to allow their personal health information to be used in medical research projects (provided that the projects have been approved and their consent is given). This is also consistent with the general positive regard in which the public seems to hold medical research. Public acceptance to use personal health information for medical research depends greatly upon expectations of how information is used and how well its use is regulated. Thus it is important to gauge public awareness of the value of research using personal health information, and level of interest in engagement on the issue. A potentially major obstacle to public engagement and acceptance of the use of personal health information in medical research comes in the shape of recent much-publicised concerns over the Government's proposed introduction of a central national database of patient information. Concerns have been raised over a perceived lack of safeguards against access to the information and the fact that patients' consent will not be sought. Other concerns are over who can view the data, with particular resistance to the police and security services having access. . . Concerns over misuse of sensitive information are particularly high when imagining a central database which holds all health information about an individual. As such, most are happier for information to be held in different locations, despite this being seen as potentially inefficient. Linked to the issue of information disclosure is security of information. There are concerns over both security of electronic records and paper. Electronic records are seen as more accurate and useful, but they are also seen as vulnerable to more abuse than paper records, mostly through ease of transfer and security breaches."
Granger: The final word (6 Jul 2007)
". . . For a man better known for savaging suppliers, with an apparent "lead me, follow me, or get out of my way' attitude, 42-year-old Richard Granger, director general of IT, NHS, is surprisingly plaintive. We met in Whitehall a few weeks before he announced his departure at the end of this year after five years in what must be the biggest, highest profile civilian CIO job in Europe. Granger has heard a lot of domestic condemnation of his role over the past five years. Critics argue the project is too complex; that it should have a more localised approach; or one based on smartcards; and that his mismanagement of finances has resulted in a £12 billion bill that is fast rocketing to £50bn. . . NHS financing will haunt Granger for the rest of his career and it is unlikely the final cost will ever be apparent. The National Programme today is said to be running at around £12bn but Granger takes issue with the current calculations. . . Also, Granger says the scope of the current programme is far larger than the original plan, something with which few commentators would disagree. It is a clear and fundamental problem with NHS IT delivery. . . It would be reasonable to surmise there is a connection between Tony Blair's long goodbye and the announcement of Granger's departure at the end of the year. But in the field, Granger has been accused of riding roughshod over the requirements of the user base and local needs. "The distribution of cost/benefit is a difficult part of seducing people to take new systems. GPs for example, bore the brunt of collecting addresses but hospitals are more likely to see the benefits." Does that mean he thinks there should be a mandate for user buy-in with public sector contracts. "Our users are highly educated. They often have quite strong opinions. I think you can do something like that in a clerical environment, like the computerisation of social security and quite a lot of my team, including me, worked on that. You built a system, test it in some offices and then roll it out. If you were a clerk administering income support, that was the system you used. There was no alternative He says the NHS is a far more complicated situation. "We were not going from a clerical process to a computerised process in a nationally controlled organisation. These organisations are statutory independent bodies, especially if they are foundation trusts. They buy services from the private sector and they've been investing a billion pounds per year in computers. Two years ago that was money for at least a decade, if not longer. You've got a lot of existing assets you must sweat. "We get a lot of views from the end user community about what is right and what is wrong and we must have a mixture of products that hopefully makes their lives easier, although sometimes we fail to do that miserably." He adds: "Sometimes we put stuff in that I'm just ashamed of. Some of the stuff that Cerner has put in recently is appalling. It really isn't usable because they have been building a system with Fujitsu without listening to what the end users want. They have taken some account but they then had to take a lot more. Now they're being held to account because that's my job."
Granger says he is 'ashamed' of some systems provided (10 Jul 2007)
"The departing head of the NHS IT programme Richard Granger has said he is ashamed of the quality of some of the systems put into the NHS by Connecting for Health suppliers, singling Cerner out for criticism. Going further than he before in acknowledging the extent of failings of systems provided to some parts of the NHS - such as Milton Keynes - the Connecting for Health boss, said "Sometimes we put in stuff that I'm just ashamed of. Some of the stuff that Cerner has put in recently is appalling." He said a key reason for the failings of systems provided was that Cerner and prime contractor Fujitsu had not listened to end users. "It really isn't usable because they have building a system with Fujitsu without listening to what end users want. They have taken some account but they then had to take a lot more. Now they are being held to account because that's my job." The latest remarks, quoted in an interview in the current issue of CIO magazine, appear to make a nonsense of Granger's June statement that unless agreement was reached between Computer Sciences Corporation and iSoft over its acquisition by IBA Health, Cerner could wind up as the system used across the whole of the English NHS. In December 2005 Nuffield Orthopaedic Centre became the first NHS site to go live with Cerner Millennium under the NHS IT programme. It has since suffered a string of problems ranging from missing appointment records, to inability to report on wait times. The Millennium system - now installed at six NHS locations in the South - remains unable to directly integrate with Choose and Book or meet 18-week reporting requirements. . . Granger also cast further light on Accenture's departure from the NPfIT programme at the end of 2006, describing their relationship with sub-contractor iSoft as a failed marriage, in which they had failed to realise their co-dependency. He contrasted the relationship with iSoft with Accenture's performance on Picture Archiving and Communication Systems with Agfa as its sub-contractor. "When they work with a mature, high quality vendor that recognises Accenture as in charge and they're doing it their way, you get a quite good deal and they'll do the job." The CfH boss goes on to state that he has been careful to avoid Stockholm syndrome -identifying with suppliers' interests rather than those of the NHS - as problems have mounted. "One supplier asked for an extra £500m to deal with cost overruns. He received a succinct refusal but there are many places where the response would have been different; where threats of bad publicity and contract disputes would persuade an organisation to start bunging millions of pounds a month in addition to the existing contract, just to cover up," says Granger. Elsewhere in the in-depth valedictory interview carried out ahead of Granger announcing his resignation, he rounds on critics and erstwhile colleagues, saying. "Either people are really stupid or evil. It's difficult to be compassionate with people who claim that suppliers are going out of business because they are not getting paid or they were withdrawing from wishing to do business with the NHS. At the same time, they are saying they [the suppliers] have been bunged millions of pounds that weren't budgeted for. It's stupid or wicked." He reserves particular ire for so-called experts. "There is a little coterie of people out there who are alleged experts and who worked on this programme. They were dismissed for reasons of non-performance or in one case, for breach of commercial confidentiality. "He actually sent our financial model to a supplier and that's why we suspended him. He then resigned which is an answer in itself." Granger continued: "Who contributed evidence to the public accounts committees? For just about every figure quoted as an expert in this programme, I've got HR files on them. They generate a piece of opinion that often substantiates their world view."
Sensitive Downing Street papers on the NHS's National Programme for IT [NPfIT] may be released (21 Aug 2007)
Computer Weekly - Tony Collins' IT Projects Blog
"The Information Commissioner Richard Thomas has ordered the disclosure of highly sensitive papers about a meeting at Downing Street which led to the launch of the UK's largest IT-based project, the £12.4bn NHS national programme. The ruling is a breakthrough in favour of openness over how Whitehall and Downing Street take decisions which lead to the award of large contracts on large and risky IT-based programmes. And it vindicates Computer Weekly's campaign against excessive secrecy over the National Programme for IT - a complaint made by many in the IT industry including the British Computer Society. The ruling comes two and half years after Computer Weekly made a request under the Freedom of Information Act for details of a seminar on NHS IT at Downing Street in February 2002, which was chaired by the then Prime Minister Tony Blair. The meeting set in train events which led to funding for what became the NHS's National Programme for IT [NPfIT]. It was attended by several ministers, the Chief Secretary of the Treasury, the Secretary of State for Health, the Chief Executive of the Office of Government Commerce, the e-Envoy, business consultants and others. The Cabinet Office, on behalf of Downing Street, twice rejected our request for information about the meeting. It claimed the information was exempt from disclosure under the Act. We appealed to the Information Commissioner in July 2005. The Cabinet Office told Richard Thomas that some of the information withheld was "used by the Prime Minister to reach decisions on the future role of IT in delivering NHS services". . . Its arguments for secrecy resembled those the government has made to resist rulings by the Information Commissioner and the Information Tribunal that early gateway reviews on the ID cards scheme should be published. Gateway reviews are independent assessments of high-risk IT-based projects and programmes. The Cabinet Office said that disclosure would inhibit frank advice given by civil servants. The Information Commissioner Richard Thomas accepted some of the arguments of the Cabinet Office but decided that other factors outweighed them. He said the information we had requested was "historical". We had made our request in January 2005, three years after the policy over NHS IT had been announced. . . He ordered the Cabinet Office to disclose the information requested within 35 calendar days of the date of his notice - 13 August 2007. Officials may appeal the decision to the Information Tribunal [link is to the Tribunal's decision to order the publication of early gateway reviews on ID cards] within 28 days."
The biggest computer programme in the world ever! How's it going? (Sep 2007)
Journal of Information Technology (Sean Brennan)
". . . In essence, the National Programme's content was agreed over the last 20 years of health IT with successive programme and projects agreeing a blueprint for the future development programme. This blueprint culminated in a clearly defined strategy for electronic records as articulated as the outcome of the national EPR Programme and the follow-up programme ERDIP. The Six Level EPR model was a reasoned pragmatic solution that was well received by both the NHS and Suppliers alike. The interactive CD Rom used to promote the model soon became a Health IT icon of its time. But its time may well come again. This comprehensive and complex programme cannot be delivered overnight and will not be delivered through a big bang. There needs to be an incremental plan and the old EPR model could be dusted off and tweaked. (The author still has copies of the original interactive CD Rom for those interested in reviewing it! For further information, visit www.eprarms.com) This model ensured the way to do it was simple and well understood. EPR would be built at a local clinical community level. It would consist of integrated clinical and administrative systems. These would produce a passive record, held locally. A national summary record (the EHR) would be fed from these local systems. 'Would be' implying that this is some future functionality and not a pre-requisite from day one. In my view, the NPfIT turned that simple approach on its head. NPfIT decided that the main objective of their programme was a single national electronic record. Most of the problems with the Programme can be traced to that fundamental re-interpretation of what the NHS needed. It might have been workable if this was allowed to evolve over time, so long as the programme's primary objective was left untouched - to put in place effective, workable local systems that support the way that healthcare professionals work in local organisations. Halfway into the programme, the LSPs have yet to convince the NHS that they really can deliver solutions and change effectively. Perhaps the scale of the challenge is just too big for them. There was a stage, in 2003, before the NHS in England was divided into five arbitrary clusters, when we all expected the delivery model to be much more local. As discussed previously, we had 28 SHAs back then, and we expected a process where 28 service providers would be appointed - one for each SHA. It is hard to escape the view that, if this had been the model, we would be looking at a Programme much closer to completion. Each local contractor would be dealing with less than half a dozen Trusts; work would have started much sooner; the relationships between Trusts and contractors would have been closer. Smaller contractors could have been lighter on their feet dealing with software delays. But multiply that up to the huge clusters that we have today, and the model becomes huge and unwieldy. Trusts who are in no hurry to move can bide their time. No one is in the spotlight. Maybe NLOP (NPfIT Local Ownership of the Programme) - due to come into force in September 2007, will change that. But even so, SHAs are much bigger now. It would not be easy to regenerate the enthusiasm for change that was so prevalent back in 2004. And will NLOP really mean a shift in decision making down to these re-defined SHAs or will the major decisions continue to be made behind closed doors and then the NHS expected to act on them? . . ."
A Computer Scientist's Reactions to NPfIT (Sep 2007)
Journal of Information Technology (B. Randell)
"This paper contains a set of personal views relating to NHS Connecting for Health's National Programme for IT (NPfIT), and in particular its Care Records Service, written from the point of view of a computer scientist, not a medical informatics expert. The principal points made are as follows:
Centralisation: Pulling lots of data together (for individual patients and then for large patient populations) harms safety and privacy - it is one by-product of excessive use of identification when in fact all that is usually needed is authentication. Large centralized data storage facilities can be useful for reliability, but risk exchanging lots of small failures for a lesser number of much larger failures. A much more decentralised approach to Electronic Patient Record (EPR) data and its storage should be investigated.
Evolutionary acquisition: Specifying, implementing, deploying and evaluating a sequence of ever more complete IT systems is the best way of ending up with well-accepted and well-trusted systems - especially when this process is controlled by the stakeholders who are most directly involved, rather than by some distant central bureaucracy. Thus authority as well as responsibility should be left with hospital and general practitioner trusts to acquire IT systems that suit their environments and priorities - subject to adherence to minimal interoperability constraints - and to use centralized services (e.g., for system support and back-up) as if and when they choose.
Socio-technical Issues: Ill-chosen imposed medical IT systems impede patient care, are resisted, result in lots of accidental faults, and lose user support and trust. All these points are attested to by rigorous studies involving expertise from the social sciences (psychology, ethnography, etc.) as well as by technical (medical and computer) experts - much more attention needs to be paid to such studies, and more such studies encouraged.
Constructive Reviews: A constructive expert review, working closely with Connecting for Health, could be very helpful, but should be evidently independent and open and thus essentially different in nature to past and current inquiries. A review of this nature could not just recommend appropriate changes of plan, and speed progress. It could also contribute to the vital task of helping to restore the trust and confidence of the public and the media in the programme and in the government officials involved."
'The biggest computer programme in the world...ever!': time for a change in mindset? (Sep 2007)
Journal of Information Technology (Chris Clegg and Craig Shepherd)
". . . In this project, there is a strong emphasis on developing and implementing a large set of IT systems. In time, the intent is that these systems will provide the technical infrastructure enabling NHS staff to deliver better care to patients. But, at least for now, the focus is on delivering the IT. This is where the budget is spent. This is what is project managed. This is what companies and people are hired to do and rewarded for doing. Put simply, this is (at present) a technology project, and indeed this is reflected in its title. We believe this 'techno-centric mindset' may be misguided, and flies in the face of lessons learned from research and practice over the last 20 or so years. While it may be the biggest programme ever, we have doubts that this is a useful way of looking upon it. Put bluntly, we question whether the current strategy is the most appropriate way forward to achieve successful service improvements. . ."
Conflicting institutional logics: a national programme for IT in the organisational field of healthcare (Sep 2007)
Journal of Information Technology (Wendy L Currie and Matthew W Guah)
"Abstract: This paper reports the findings from a 4-year study on the UK National Health Service on the introduction of a national programme for information technology. This is the largest civil IT programme worldwide at an estimated technical cost of £6.2 billion over a 10-year period. An institutional analysis of our historical and empirical data from six NHS organisations identifies growing fragmentation in the organisational field of healthcare, as past and present institutional logics both fuel and inhibit changes in the governance systems and working practices of healthcare practitioners. This is further complicated by new institutional logics that place the citizen at centre stage of the NPfIT, in a move to promote patient choice and public value."
Modernising healthcare - is the NPfIT for purpose? (Sep 2007)
Journal of Information Technology (Annabelle L Mark)
"Abstract: This paper responds to the findings of the research by Currie and Guah on the introduction of the National Programme for Information Technology through an institutional theory perspective. It considers both the appropriateness and applicability of the method chosen in the light of what is already known about UK healthcare organisations and the complex and changing process that is involved in both the organisation and any research that takes place. This is further confounded by an unstable political environment both nationally and locally and a failure to understand the changing location, role and status of the medical record. Only when this is resolved will a transformational change occur, in line with the new patient-focused government agenda and the external world of technology that must engage with the emotional as well as the rational role that both technology and health play in people's lives."
Local sociotechnical system development in the NHS National Programme for Information Technology (Sep 2007)
Journal of Information Technology (Ken Eason)
"Abstract: The National Programme for Information Technology is implementing standard electronic healthcare systems across the National Health Service Trusts in England. This paper reports the responses of the Trusts and their healthcare teams to the applications in the programme as they are being implemented. It concludes that, on the basis of the data available, it is likely that the emergent behaviour of healthcare staff will serve to minimise the impact of the systems. The paper looks at the opportunities within the programme to undertake local sociotechnical system design to help staff exploit the opportunities of the new electronic systems. It concludes that there are opportunities and offers one case study example in a Mental Health Trust. However, it concludes that there are many aspects of the technical systems themselves and also of the approach to implementation, that limit the opportunities for local sociotechnical systems design work."
Our Future Health Secured? - A Review of NHS Funding and Performance (Sep 2007)
Kings Fund (Derek Wanless, John Appleby, Anthony Harrison, Darshan Patel)
". . . The NHS Care Records Service (NCRS) aims to provide an electronic health care record for every patient in England. The NHS Plan noted that this could become a reality by 2004, when 75 per cent of hospitals and 50 per cent of primary and community trusts would have implemented electronic patient record systems. However, controversy has seriously undermined this aspect of the NPfIT, partly due to the absence of any published plans for the design and implementation of NCRS. It is also unclear what information will be held on individual electronic health care records. Doctors and patient groups remain anxious about who will have access to electronic patient records and the associated risk to patient confidentiality. The government has now agreed to allow patients to "optout" of having their records held by NCRS, although the details of the opt-out procedures have not been settled. Consequently, real progress is only just beginning. In the spring of 2007, a number of early adopters began creating "summary care records" as a prelude to the national roll-out. These records are expected to include significant elements of a patient's care, including major diagnoses, procedures, current and regular prescriptions, allergies, adverse reactions, drug interactions and recent investigation results. However, this will be a challenge. National roll-out is expected to begin early in 2008, but it will be several years before coverage is complete. A date has not yet been specified for the system to be fully operational. . . A detailed review of NPfIT is beyond the scope of this report, but three factors seem likely to have an impact on the 2002 review's productivity assumptions. The first is the failure to develop an ICT strategy whose benefits are likely to outweigh costs. The NAO (2006) noted that "...it was not demonstrated that the financial value of the benefits exceeds the cost of the Programme". This is a serious criticism, implying either the absence of an original business case for investment or investment made in spite of a business case that did not justify the spending. In similar vein, a report by the British Computer Society (2006) concluded that "... the central costs incurred by NHS [Connecting for Health] are such that, so far, the value for money from services deployed is poor". Surprisingly, systematic reviews of ICTs show that evidence for key technologies, such as NCRS and PACS, is lacking (Delpierre C et al 2004; Poissant L et al 2005). It is difficult to understand why Connecting for Health is being allowed to pursue a high-cost, high-risk strategy that cannot be supported by a business case. Second, while the 2002 review assumed that investments would be audited and evaluated, apart from the NAO report the necessary work is not being undertaken and it does not seem possible to obtain reliable data on NHS resources being committed to NPfIT. Connecting for Health has so far made negligible investments of less than £0.5 million in evaluation (a fraction of the projected £12.4 billion costs). There seems a real risk that the costs and benefits of NPfIT will never be accurately assessed. The third factor, which may turn out to be the most important, is that the NPfIT contracts risk creating monopolies in various areas of the programme. The House of Commons Public Accounts Committee (2007a) has noted that "The use of only two major software suppliers may have the effect of inhibiting innovation, progress and competition". Connecting for Health chose to award a small number of large contracts to consortia charged with designing and implementing the technologies. But they could instead have set out to create a competitive market for IT goods and services. Is it possible that a robust business case could be created, even now, with a focus on strategies for encouraging a healthy market? It is clear that there are considerable challenges ahead in modernising NHSIT systems, and continuing debate over the feasibility of some current NPfIT plans. The continuing uncertainty and delays have the potential to undermine the productivity gains envisaged by the 2002 review. . ."
Potential contributions to developing EHRs (2 Dec 2007)
BCS Health Informatics Now
". . . Lincoln Moura Jr gave a snapshot of a city-wide electronic health record project covering 22 million people in Sao Paolo and the surrounding area. It has 400 primary care units, 160 polyclinics, 105 hospitals and 7 million patients. Open standards and open source code was being used where possible, and national standards were to be promoted if not fully complied with. The project team was assembled in January 2004, with deployment in September of the same year. New features were added up until March 2005. Currently 13 million people are registered and 30,000 appointments scheduled daily. The project's success is attributed to the software engineering principles used, an integrated project management process and some exceptional talent. . ."
Evidence from other shores can benefit UK (2 Dec 2007)
BCS Medical Informatics Now
"What can the UK learn internationally in health informatics? . . . [Though] issues such as telemedicine and home monitoring are important, in most people's minds in the UK the key issue in health informatics is electronic records, and here the NHS has very specific policies - four of them, one for each home country. Can we really learn here? Surely the question must be considered the other way round: we expect clinicians to practice evidence-based medicine, so are not informaticians - and informatics policy makers - duty bound to practice evidence-based health informatics, and to ground their action on the best available evidence? It is here that it is clear that the UK could learn more from looking outside its shores - not in any sense of deference, but in one of scientific enquiry. Yet the policy evidence base of UK health informatics is not striking, with the four home countries not emphasising independent underpinning evidence, let alone collaborating on determining what is best in the UK situation. There is a strong tendency to look to the United States, where many vendors and regularly cited implementations are based, and where the influential Institute of Medicine's (IOM) study on the computer-based medical record1 was published. But the US health system and its commercial basis are very different to the UKÃ�Â¢Ã¯Â¿Â½Ã¯Â¿Â½s, and the IOM study has neither metrics nor costings - it is a vision, not a blueprint. But from the United States there is a considerable literature on barriers and enabling factors to clinician uptake of EPR systems, which seems to have been largely ignored as inconvenient. So in this case the learning has been of the wrong type - the conceptual and organisational-level material has been followed, even though the two health systems are very different, but the individual clinical behaviour which has much greater similarities has been ignored. So how can and should the UK learn internationally? One start would be to recognise that our greatest links are with Europe. Not least, all European health systems have strong values of equity, accessibility, and affordability at the time of need. . ."
Evidence from other shores can benefit UK (Dec 2007)
BCS Health Informatics Now
". . . there is much that can be learned, as well as contributed, by the UK in health informatics internationally. This can be to the benefit of informatics practitioners, but above all to systems, their implementing organisations and thus patients. It is time that this was seen as a legitimate - indeed required - activity, in a move to better informed and evidence-based informatics. Indeed there is some enlightenment, as exemplified by Wales specifically setting up an International Advisory Group to regularly review its health informatics progress. Is this the beginning of an age of enlightenment on learning from outside views and evidence?"
Data sharing on a par with nuclear radiation (Dec 2007)
BCS Health Informatics Now
"Given the dangers of highly sensitive medical data falling into the wrong hands, implementing the right controls to protect confidentiality are vital. As moves accelerate towards the nationwide sharing of records, four speakers at a BCS event looked at different aspects of making sure that private data stays that way."
Visualizing Electronic Health Records With "Google-Earth for the Body" (Jan 2008)
"Andre Elisseeff leads a research team at IBM's Zurich Research Lab that in September demonstrated a prototype system that will allow doctors to view their patients' electronic health record (eHR) using three-dimensional images of the human body. . . "You can think of it as being like Google Earth for the body," is how Elisseeff frames the mapper engine. "We see this as a way to manage the increasing complexity that will come in using computers in medicine." A major driver of that complexity is the push by governments worldwide to computerize paper-based medical records. "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care," said President George W. Bush in his 2004 State of the Union address. In that speech he called for the computerization of the nation's medical health records. In April 2004 Bush issued an executive order to accomplish this by 2014. Although our ability to meet the 2014 date is highly doubtful, progress is being made toward defining the underlying standards necessary for creating a national, interoperable automated health-record system. The United States is following the lead of other countries, such as the United Kingdom, Australia, Canada, Finland, Germany, and Denmark, each of which has introduced national programs to eliminate paper-based medical records and replace them with some form of eHR. The UK's computerization effort, called the National Programme for IT (NPfIT), is considered by many to be the largest nonmilitary IT program ever undertaken. However, not all is well on the eHR front, not only because of the technological difficulties involved (for instance, the NPfIT implementation, like most national eHR efforts, has experienced both schedule slips and rising costs) but because of the resistance of both physicians and patients to the presence of computers in the exam room. Many doctors complain that eHRs have turned them into clerks, while patients say that doctors using these automated systems seem more interested in typing on their computer keyboard than in listening to their health problems. Instead of capturing unstructured data from a conversation between doctor and patient, "most of the electronic health record systems have been built as if physicians and clinicians were office workers entering in structured administrative data," says Elisseeff. This clerical approach to these system designs implicitly excludes the patient as an active participant and makes the computer an intrusive third party to what are often difficult personal discussions. . ." [Robert N. Charette]
Secrets of Blair briefing on NPfIT to be surrendered (4 Feb 2008)
"The government is taking the unprecedented step of releasing papers on how policy decisions were taken at Downing Street before the launch of the NHS systems modernisation project - the world's largest civil IT-based scheme. The move follows a three-year campaign by Computer Weekly to force disclosure of the "Downing Street papers", using the Freedom of Information Act. The disclosures, which are expected to be made this week, will mark the first time Whitehall has made a major release of secret information on how policy decisions over large and risky IT projects and programmes are taken. In 2005, days after the Freedom of Information Act came into force, Computer Weekly formally applied for details of an IT seminar held at Downing Street in February 2002, chaired by the then prime minister, Tony Blair. Decisions at the seminar led to the launch of what became the £12.4bn National Programme for IT in the NHS. The government formally rejected Computer Weekly's request three times. The case was due to come before the Information Tribunal on 11 February, but last week the government's lawyers unexpectedly withdrew from the appeal. The Cabinet Office will now release the information. The NHS IT programme has been dogged by problems and Computer Weekly has sought information on whether the risks were sufficiently discussed and assumptions challenged. Papers now expected to be released include: A submission to the prime minister explaining the background to the meeting and giving him a steer on questions to raise; A record of what was said at the Downing Street meeting. Two months ago Computer Weekly submitted a paper to the tribunal setting out the public interest arguments in favour of disclosing the Downing Street papers. The tribunal decided formally to accept our evidence as part of the case, which appears to have been a factor in the decision of the Cabinet Office to withdraw its appeal. . ."
Granger era ends as DG leaves CfH (7 Feb 2008)
"Richard Granger has left NHS Connecting for Health, the NHS IT agency responsible for the £12.4bn NHS IT programme, which he has led for the past five years. CfH staff and NHS chief information officers began to be notified of Granger's departure this morning. The announcement ends a period in which it has been unclear how closely involved Granger has been in running CfH. He had originally been due to quit by the end of 2007, after announcing in July that he would 'transition' from CfH. A DH spokesperson told E-Health Insider this morning that Granger will not be replaced by an equivalent director general, but instead by a new director of programme and systems delivery at CfH. A new role of Chief Information Officer will be created, based in the DH, covering both the DH and NHS. The spokesperson said: "We've just had Cabinet Office agreement that we can go ahead and start filling these roles." Until these recruitments are completed Matthew Swindells, who is currently leading the DH's Informatics Review, with act as the DH's CIO. Gordon Hextall, the chief operating officer of CfH will act as director of programme and systems delivery. . ."
Google Health unveils electronic record pilot (22 Feb 2008)
"Google has teamed up with the prestigious Cleveland Clinic in the US to pilot a system which lets patients transfer their existing medical information to its new online Personal Health Record (PHR) service, Google Health. Once transferred to Google Health patients will then be able to manage and control access to their records, deciding who they want to share them with. In a keenly-anticipated announcement the internet search giant said it will manage the electronic health records for almost 10,000 Cleveland Clinic patients who currently use the hospital's online health records system. Patient participation is voluntary. The Google Health pilot will test secure exchange of patient medical record data such as prescriptions, conditions and allergies between their Cleveland Clinic PHR to a secure Google profile in a live clinical delivery setting. A Google UK spokesperson told EHI the service will only be made available in the US initially, with global expansion to be considered in the future. The ultimate goal of this patient-centered and controlled model is to give patients the ability to interact with multiple physicians, healthcare service providers and pharmacies. . . A Google spokesperson stressed to E-Health Insider that they have no plans to add providers to the pilot or to sell or share data without explicit patient consent. The system will initially run in the US, and global expansion will be considered in the future . ."
Majority of NHSmail accounts are inactive (25 Mar 2008)
Kable's Government Computing
"The secure email and directory system for England and Scotland's health services has 153,000 active accounts, less than half the 337,000 registered users. The number of active users is a small fraction of the NHS employees within the two nations, which exceeds 1m. In April 2006, then director general of NHS Connecting for Health Richard Granger challenged health service organisations to turn off local email systems in favour of NHSmail. The figure for active users was provided by health minister Ben Bradshaw in a parliamentary written answer on 19 March 2008. The number has grown by 40% over the last 12 months, from 109,548 at the end of February 2008 to 153,073 on 29 February 2008. NHSmail is provided free of charge for all health service staff in the two nations, with staff able to retain their email addresses when moving between health service organisations. The system was originally run by EDS, but its contract was terminated after six months. NHSmail is now provided by Cable & Wireless, but last year, the system was moved from that company's Mirapoint email system to Microsoft Exchange 2007, as part of a widening of Connecting for Health's agreement with Microsoft."
Warning on Storage of Health Records (17 Apr 2008)
New York Times
"In an article in The New England Journal of Medicine, two leading researchers warn that the entry of big companies like Microsoft and Google into the field of personal health records could drastically alter the practice of clinical research and raise new challenges to the privacy of patient records. The authors, Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane, are longtime proponents of the benefits of electronic patient records to improve care and help individuals make smarter health decisions. But their concern, stated in the article published Wednesday and in an interview, is that the medical profession and policy makers have not begun to grapple with the implications of companies like Microsoft and Google becoming the hosts for vast stores of patient information. The arrival of these new corporate entrants, the authors write, promises to bring "a seismic change" in the control and stewardship of patient information. Today, most patient records remain within the health system - in doctors' offices, hospitals, clinics, health maintenance organizations and pharmacy networks. Federal regulations govern how personal information can be shared among health institutions and insurers, and the rules restrict how such information can be mined for medical research. One requirement is that researchers have no access to individual patients' identities. Under the current system, individuals can request their own health records, but it is often a cumbersome process because information is scattered across several institutions. As part of a push toward greater individual control of health information, Microsoft and Google have recently begun offering Web-based personal health records. The journal article's authors describe a new "personalized, health information economy" in which consumers tell physicians, hospitals and other providers what information to send into their personal records, stored by Microsoft or Google. It is the individual who decides with whom to share that information and under what terms. But Microsoft and Google, the authors note, are not bound by the privacy restrictions of the Health Insurance Portability and Accountability Act, or Hipaa, the main law that regulates personal data handling and patient privacy. Hipaa, enacted in 1996, did not anticipate Web-based health records systems like the ones Microsoft and Google now offer. The authors say that consumer control of personal data under the new, unregulated Web systems could open the door to all kinds of marketing and false advertising from parties eager for valuable patient information. Despite their warnings, Dr. Mandl and Dr. Kohane are enthusiastic about the potential benefits of Web-based personal health records, including a patient population of better-informed, more personally responsible health consumers. "In very short order, a few large companies could hold larger patient databases than any clinical research center anywhere," Dr. Mandl said in an interview. But the authors see a need for safeguards, suggesting a mixture of federal regulation - perhaps extending Hipaa to online patient record hosts - contract relationships, certification standards and consumer education programs. . ."
Newcastle chooses Pittsburgh for EHR (29 Apr 2008)
Newcastle upon Tyne Hospitals NHS Foundation Trust has partnered with the University of Pittsburgh Medical Centre (UPMC) to deploy electronic health record technology at Newcastle's hospitals. Under the 14-month implementation plan, a UPMC technology team will install and adapt five electronic health record (EHR) applications at five Newcastle hospitals, including the Royal Victoria Infirmary, Freeman Hospital and Newcastle general Hospital, with a total of over 2,000 beds. The five applications to be installed include inpatient order entry, patient administration, pharmacy management, accident and emergency services and operating room systems. Details of the applications to be used or the value of the deal were not disclosed. UPMC and Newcastle have also formed a joint venture to provide IT services to other UK hospital trusts. "Newcastle will be an important proving ground for this partnership," said Len Fenwick, chief executive of Newcastle Hospitals. "We are confident that others will soon see the value of what we are doing here and seek to replicate it." UPMC has regularly been voted one of the leading hospital groups in the US for its use of IT. Systems used by UPMC include: Epic System's EpicCare for outpatient electronic medical records, Cerner's PowerChart for electronic medical record management, Medical Archival Systems, Inc. for patient notes, Stentor for digital imaging, remote access tools and a physician portal. . . "The Newcastle contract is the first of what we hope will be many international agreements for our information etchnology services," said Dan Drawbaugh, chief information officer at UPMC. Donna McCormick, CIO of UPMC's international and commercial services division will be based in London to oversee the Newcastle project and other UPMC international technology initiatives. . . Explaining why it has gone outside the NPfIT programme the trust said "Because of its long-standing commitment to using advanced technology to improve patient care, Newcastle sought an outside technology partner to implement elements of an electronic health record. Through a competitive bidding process, it selected UPMC as its prime contractor. The new system is expected to be fully compatible with the UK's national programme for electronically connecting hospitals."
How a Sociotechnical approach can help NPfIT deliver better NHS patient care (May 2008)
Centre for Organisational Strategy Learning and Change, Leeds University Business School Malcolm Peltu, Ken Eason and Chris Clegg)
". . . This paper seeks to show how sociotechnical thinking and practice can be of practical benefit within NPfIT - provided the programme adopts a more holistic overall strategy that places social and organizational issues alongside technology concerns at the heart of its work. The methods recommended are based on sociotechnical design principles which have been successfully applied in many environments over more than fifty years. The optimists at the [7 Feb 2008 BCS] meeting claimed there are opportunities to use this knowledge to improve outcomes in many NPfIT implementations, although others expressed doubts about the extent to which this would happen. This paper starts by summarising the nature of NPfIT's current strategy and the main problems it has encountered. It then identifies key sociotechnical design principles relevant to overcoming such problems, explaining why the sociotechnical view is well positioned to address key barriers to the success of NPfIT. Guidelines on applying these principles offer a way of realising the enormous potential benefits which are made possible by the use of IT capabilities in delivering healthcare. . ."
Is the Treatment Working? (Jun 2008)
"Since the government announced the NHS system reform programme in 2000 in the NHS Plan, the NHS has made significant progress. There are shorter waiting times and the quality of care overall, as measured by the annual health check, has risen. This report examines the impact of the system reform programme on the progress made. It concentrates on some key aspects of the reforms: patient choice, Payment by Results (PbR), practice based commissioning (PBC), foundation trusts (FTs), greater NHS use of the private sector through the introduction of independent sector treatment centres (ISTCs), and the impact that major workforce contractual changes have had on hospital efficiency. . . There have been significant delays in the roll out of electronic patient records as part of the National Programme for IT, Connecting for Health. Many of the organisations involved in our research were frustrated with the pace of implementation for Connecting for Health and that its structure, at times, was perceived neither to match local needs nor offer an improvement to existing systems. Even PbR, the most fully implemented reform, has been hampered by a lack of supporting infrastructure, for example, in the provision of data. For example, as stated in The Right Result? (Ref. 10), the timeliness and quality of data available to PCTs through the secondary uses service (SUS)I for monitoring contracts and making payments under them need significant improvement. . . The necessary infrastructure is also not yet in place to enable choice to reach its full potential. The national roll out of Choose and Book, the electronic booking appointments system, was delayed. This has limited the choice that patients had over access to outpatient appointments. In addition, the NHS Choices website only went live in July 2007; the information it contains is still incomplete; and not all patients will have access to this medium. Chapter 3 explains how choice policy is being hampered by the lack of necessary information on patient care, although the DH are now addressing this. PBC is also yet to deliver significant change and the slow progress can be attributed at least in part to underdeveloped budgeting, data collection and information sharing and governance processes. . ."
Conservatives commission review of NHS IT (21 Aug 2008)
"The Conservative Party has commissioned an independent review of NHS IT policy. The review is intended to inform future government policy for the use of IT in the NHS, health and social care in England. The review will aim to establish a vision for IT in the NHS, health and social care and inform the policy actions the current and any future government should take. Chaired by Dr Glyn Hayes, the former chair of the BCS Health Informatics Forum, the new review has been commissioned by, and will report back to, the Conservative shadow health minister, Stephen O'Brien. Dr Hayes told E-Health Insider that the he only agreed to lead the review after being assured of its independent nature. "The BCS is apolitical," said Dr Hayes. He stressed that he intended the review to focus on developing a pragmatic blueprint to get the maximum patient benefit from IT and informatics in health and social care, and not to dissect the existing National Programme for IT in the NHS. He said the first requirement was to define a clear shared "vision of what the future holds for the next five to ten years". Dr Hayes said the roots of the review could be traced back to the Commons' Public Accounts Committee review of the national programme, which first recommended that such a review should be conducted. However, he said the review "may inform the development of Conservative party policy in this area." Dr Hayes said the review will not be retreading the ground covered by the recent Health Informatics Review, which was carried out by the Department of Health. He said it had really only looked at the way forward for the DH and NHS Connecting for Health. And he argued it had failed to consider a number of key areas in sufficient detail. While the review focused on information sharing across the health service, for example, Dr Hayes suggested that some of the greatest benefits came from ensuring information was available "at the point of patient care." The plan is to carry out the review rapidly, with all written evidence to be submitted by the end of September. This phase will be followed by oral hearings in October and November. A first draft is to be produced in December and the final report is to be published by the end of March 2009. "The review will be published as an independent review and then it will be for the Conservative party to decide whether to adopt some or all of the policy recommendations," said Dr Hayes. Secretarial support for producing the report will be provided by the Conservative party. The review group has already been formed, with members from primary and secomdary care already confirmed. It has issued an invitation for written evidence from individuals and organisations involved in health and social care. . ."
Newcastle NHS trust quits the NPfIT ship (10 Sep 2008)
"Patrick Kesteven, a consultant haematologist at Freeman Hospital, Newcastle, is open and clear-minded when talking about why his trust board decided to break away from the £12.7bn National Programme for IT in the NHS. "The National Programme was taking forever," he says. He is not even sure that the National Programme for IT (NPfIT) - the UK government's biggest IT investment - will ever work as originally intended. Far from being a renegade, Kesteven is ensconced in Newcastle's medical establishment. He chairs a programme board which is planning for a system of e-records to start going live at three hospitals in Newcastle in May next year. Executives at the Newcastle Upon Tyne Hospitals NHS Foundation Trust, which employs 11,000 clinical and administrative staff, have given up waiting for e-record systems from the NPfIT. They want as soon as possible to give doctors and nurses systems which, with a single log-on, provide an overview of patients' treatments and histories, who is supervising them, where they are in the hospital and whether, for example, they have just had an adverse reaction to a general anaesthetic. The trust also wants better information to ensure it is paid for all it does. When patients are given extra treatment unrelated to their initial problem, the work can go unrecorded on existing payment-related systems. The NPfIT was specified to provide the solutions, but the government promised it would be in place by 2006. When ministers announced the NPfIT in 2002, they promised that patients would have a national electronic health record by the end of 2005. That has not happened, nor is it expected to happen for years. The National Audit Office says it will be 2015 before a national e-records scheme will be rolled out across England, and believes even that date may be optimistic. So the Newcastle board has decided to buy its systems from the US University of Pittsburgh Medical Center, which has introduced an integrated e-records system at its 20 hospitals. The purchase cuts out CSC, the national programme's local service provider to NHS organisations north of Oxford. It also sidelines NHS Connecting for Health, the 1,100-strong bureaucracy in the Department of Health which is running parts of the NPfIT. Newcastle and Pittsburgh Medical Center have formed a joint venture whose directors hope to sell licences and implement systems to NHS organisations. Other foundation trusts have been inquiring about Newcastle's approach to major IT investment, says a report to the trust's board. Foundation trusts have the freedom to buy outside the NPfIT if they have good financial reasons for doing so. Non-foundation trusts must buy their main hospital system - the patient administration system - under the NPfIT, although there are exceptions. Monitor, the regulator of NHS foundation trusts, is aware of Newcastle's plans to buy outside the NPfIT. Newcastle's board has been told that Monitor "understood that the trust could not wait until 2012/13 for the national programme to provide the required systems". If many foundation trusts diverge from the NPfIT, the government's plan to supply England's NHS trusts through a small group of appointed IT companies - local service providers - will disintegrate further. Already, non-foundation trusts in the south of England are considering "interim" systems not supplied by the scheme's two remaining local service providers, BT and CSC the contract of the third provider, Fujitsu, was terminated. Tola Sargeant, an NPfIT expert at market analyst Ovum, says that the "lull" in the NPfIT, mainly in southern England, creates opportunities for suppliers other than CSC and BT. . . The Newcastle trust is the first organisation outside the US to invest in Pittsburgh Medical Center's Cerner-based e-records technology. Kesteven recognises that not all staff at Pittsburgh Medical Center are enamoured with all aspects of the system. "But would they go back to how things were before? They couldn't imagine it." There is also the challenge of making a US system work in the UK. Anglicisation will be the key, Newcastle has been told. If the Newcastle implementation goes badly - as did a basic version of the Cerner system when it was deployed at some NHS trusts in London in the south of London - health officials in Whitehall may say it serves the trust right for not waiting for the free (because centrally funded) NPfIT systems. But Newcastle's executives see the risks as worth running. They have learned the main lesson from the troubled installations of the NPfIT Care Records Service in London and the south of England: that the customer must be in control of the supplier, the contract, the software's functionality and the changes in the day-to-day working practices of doctors and nurses. . . Even with their own IT contracts in place, Newcastle's directors know it will be difficult trying to combine information on its patients, given that data is held in up to 100 legacy systems across its various sites. Andre Snoxall, e-record programme director at the Newcastle trust and a former CIO at trusts in New Zealand, says that even with the most favourable conditions and contracts it is still an enormous task to bring about a comprehensive view of a patient with a single log-on. "It takes an extraordinary amount of effort to try and get a full picture of a patient's history," he says. He adds that the biggest challenge for the trust is not so much technology as inspiring people, engaging them and "getting them working towards a common goal". And if achieving a single patient view at one large trust alone is hard enough, the government aims to do it for all hospitals across England. Standardised systems, no contractual relationship between most trusts and their suppliers, little customer control over changes to the software, and delays of at least four years so far are just some of the obvious problems. Kesteven will gain some sympathy from some NHS IT executives for his view that the NPfIT may never happen. That should be a prompt to the government to rethink the programme or conduct a high-level review, which it has so far repeatedly refused to do. . ."
E-records without a central database? (11 Sep 2008)
Tony Collins' IT Projects blog
"The Newcastle Upon Tyne Hospitals NHS Foundation Trust is considering an interesting product, dbMotion, which allows doctors and nurses to see a patient's medical history even when parts of it are in many different legacy systems, without establishing a central database. The product is among the healthcare IT systems sold by the University of Pittsburgh Medical Center, with whom Newcastle Upon Tyne Hospitals NHS Foundation Trust has a joint venture, outside of the NHS's National Programme for IT [NPfIT]. Clalit Health Services, the largest health maintenance organization in Israel, which has 32,000 employees, uses dbMotion at its 14 hospitals. It says the principles are:
- No central database. "All the information stays where, and in the same format, it was created" so there is "no need to replace any of the legacy systems":
- No single point of failure
- Rigid security and privacy
- Performance - average. response times, end to end of eight seconds or less.
- Use for viewing only - saving data not allowed
Clalit says of dbMotion that it "securely shares medical information, creating a virtual patient record by connecting a group of care providers and organisations without requiring data centralisation". Professor Brian Randell of the School of Computing Science at Newcastle University briefly summarised the way products such as dbMotion work in his paper "A Computer Scientist's Reactions to NPfIT". Randell is one of 23 computer scientists who wrote an open letter to the House of Commons' Health Committee calling for an independent review of the NPfIT. He said in his paper: ". . . the concept of an EPR [electronic patient record] should be abandoned in favour of that of using an 'information broker' to enable the accessing of information that is gathered as appropriate for each particular purpose from multiple specialised record repositories. Such a broker can be regarded as implementing what are in effect 'virtual EPRs'. In fact, Connecting for Health already endorse one software system - Miquest - that works this way, extracting data from different types of general medical practice computer systems, and this is the approach taken very successfully in Israel by Clalit Health services."
Lib Dems urge immediate halt to NPfIT (17 Sep 2008)
"The Liberal Democrat shadow health secretary Norman Lamb has called for an immediate end to further spending on the NHS National Programme for IT. He also pledged an independent inquiry into the £12.4bn project to computerise the health service, which he said had been "a shambles from the start". "We believe the gains possible from the use of IT would more likely be realised if the programme were decentralised and control given to local organisations who could instead work on improving connectivity between health and social care," Lamb said in a statement to GC News. His comments followed a speech yesterday at the Liberal Democrats' annual conference in Bournemouth, in which he said the party would create local health boards with a legal duty to deliver value for money in securing health care. Central imposition of private-sector providers would be rejected. "And it's goodbye to the National IT programme, which has and will waste billions of pounds," Lamb told the conference. "Besides - who would trust this government with a national database of our medical records?" In keynote speeches, party leader Nick Clegg and his treasury spokesperson, Vince Cable, both attacked the government's record on IT programmes. Both promised to an end to the National Identity Scheme; Clegg claimed a "computerised bureaucracy" had replaced face-to-face contract; and Cable said the party would also stop "the gravy train of management consultancy in government"."
NHS procurement systems are 'wasteful and block innovation' (6 Jan 2009)
"Procurement policies in the National Health Service are hindering the uptake of new technology and working practices, according to a new report.The poor adoption of new technology was "one of the reasons our standards often fall below those of comparable countries", said the report titled All change please from think tank The Policy Exchange. The study, based on detailed interviews with UK and US health care professionals, takes a swipe at the National Programme for IT (NPfIT) in the NHS, which is driving through a £12bn computerisation project. It is not the core technology that is at fault, according to the authors, rather it is the basic approach. The report is critical of the US health care system. For example, it states, "Compared with many other industrialised nations, the American healthcare system as a whole ranks near the bottom on important measures of performance. It lags behind other countries in the adoption of information technology that could improve quality and efficiency. Nevertheless, it identifies the University of Pittsburgh Medical Centre as an example of best practice. Its technology supplier is Cerner, which is also the supplier of core systems for London where deployment has hit a number of problems. The report states: "The lesson (from University of Pittsburgh Medical Centre) is that IT has to adapt to clinical practice, rather than the other way round, a mistake made by the National Programme for Information Technology (NPfIT) in the UK, which has attempted to impose a standardised solution for every hospital in the NHS. In contrast, UPMC has developed different applications for its academic, community and paediatric hospitals to reflect their different needs." . . ."
Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions (9 Jan 2009)
Committee on Engaging the Computer Science Research Community in Health Care Informatics, National Research Council
". . . The National Library of Medicine launched this study to support the engagement of individuals from the computer science research community in meeting two challenges posed by health care information technology: identifying how today's computer science-based methodologies and approaches might be applied more effectively to health care, and explicating how the limitations in these methodologies and approaches might be overcome through additional research and development. The study described in this report was conducted by an interdisciplinary committee of experts in biomedical informatics, computer science and information technology (including databases, security, networking, human-computer interaction, and large-scale system deployments), and health care providers (e.g., physicians who have worked with information technologies). . ."
The Data Model That Nearly Killed Me (17 Mar 2009)
Syleum: Analysis From the Bottom-Up
". . . During the last week of January 2009 a faulty electronic, networked, health information data model nearly killed me despite its vaunted status as a component of two state-of-the-art, health information systems at two of the world's most advanced medical facilities. This will come as no surprise to healthcare IT experts because health information is inherently complex, medical science develops extraordinarily rapidly, patient interactions are intensely personal, and the number of data types and sheer volumes of healthcare data explode prodigiously with new tests, instruments, and treatments. . . Medical personnel at urgent care and the hospital who interacted with me all used a version of the same electronic health information system (the 'system'). It became clear that everyone was fighting that system. Indeed, they wasted between 40% and 60% of their time making the system do something useful for them. The system kept everyone from fulfilling their duties - the health information system did not help medical professionals perform their duties. . . The national health information network envisioned by President Barak Obama is a pipedream. That is, unless and until information technology (IT) professionals learn how to build systems and data models that meet end-user requirements (read, useful to medical professionals). My recent experience with an urgent care clinic and a major tertiary care hospital convinced me that the United States will require a long time before there is a consistent data model capable of recording a patient's health information, let alone a data model capable of accurately and reliably transmitting that information from one healthcare institution to another. . ."
Newcastle prepares for go-live (16 Jul 2009)
Newcastle upon Tyne Hospitals NHS Foundation Trust is preparing to go-live with the electronic patient record system for which it partnered with the University of Pittsburgh Medical Centre last year. Trust director of programmes André Snoxall told E-Health Insider that despite some minor delays the trust is "cautiously optimistic" that it will go live with the Cerner system at the end of August. "The main issue has been the extent and complexity of migration of data, which has placed a stress on the dates," he said. "There have also been issues with compliance with NHS Connecting for Health, which has really stressed us and has been far more complex than anticipated." In April 2008, Newcastle announced that a UPMC implementation team would help it to install and adapt five electronic patient record applications at five city hospitals. The trust's decision to award an EPR contract outside the National Programme for IT in the NHS came after it rejected the solution offered by its then-local service provider Accenture. Instead, it placed an advert in the Official Journal of the European Union. After monitoring developments following the appointment of a new LSP, CSC, it decided to continue its move outside NPfIT and partner with UPMC. Snoxall said: "It's the first time CfH have tried to engage with an individual trust, because usually they deal with large organisations as part of NPfIT. So far, every facet of what we have done has been investigated by CfH, with a single person managing every point of the contract." The trust intends to go-live with the new Cerner Millennium PAS at the end of August. This will include admission, transfer and discharge summaries, booking and scheduling of theatres and Choose and Book. "This will all go live across the whole trust, 1,500 beds and 11,000 staff," Snoxall said. At the end of September, the trust hopes to go-live with investigations ordering and results review, which will initially be rolled out at the Freeman Hospital. Electronic prescribing will be rolled out in phases until October next year. Snoxall said: "The roll-out will again begin at the Freeman Hospital and move from one area at a time until October 2010. We will then look at further changes and when those have been made it will be rolled-out in more delicate areas, such as intensive care." He added the trust is trying to strike a balance between going live on a specific date and going live when the system is right. "We are trying to be sensible by not sticking to particular dates and are continuing to fix the problems with data as we come across them. We're just taking things one step at a time in order to manage risk effectively and be well informed as to when we are ready to go-live," he said. Training began last month to ensure that all administration and nursing staff are fully trained before the PAS goes live. Clinicians will receive online training, which is being developed. The trust is also issuing a newsletter and running open invitation sessions every two weeks to keep staff updated on the programme's progress. These are "extremely well attended." Snoxall said that around 25 people from UPMC and Cerner and are onsite all day, every-day, working alongside a 25 strong programme team, which is also working "flat out." He said: "The integrator, UPMC, has contracted Cerner into providing the support for us so this is a very much a fully engaged partnership, which is really helping us to get across the line."
Independent Review of NHS and Social Care IT (Aug 2009)
Commissioned by Stephen O'Brien MP, Chaired by Dr Glyn Hayes
From the Executive Summary:
Since its inception in 2002, the Government's National Programme for IT (NPfIT) has remained the largest civilian IT project in the world. Not only is it unrivalled in scale, the complexities of healthcare data and information mean that the use of IT poses an infinitely greater challenge in the NHS than in other sectors where information is more objective and absolute. Nevertheless, there is universal consensus that, if this challenge is met, the use of information systems in the NHS will bring about significant improvements to the delivery of patient care. Patients can also benefit from the enhanced communication channels that IT can forge between health and social care. The National Programme for IT should not, therefore, be abandoned, as some are suggesting it should be. Rather, it must be adapted and recast to better meet the needs of patients. The Review Group has reached a number of conclusions as to how the National Programme for IT or a successor programme can best address the challenges posed by the NHS and deliver long-term improvements to patient care.
Newcastle set to switch on Millennium (6 Nov 2009)
The Newcastle upon Tyne Hospitals NHS Foundation Trust is planning for a "low-key" go live of its new Cerner Millennium electronic patient record system tonight. The trust has declined to confirm that it is planning of going live this weekend, but E-Health Insider understands the trust aims to go live this Friday. Newcastle is planning one of the largest ever hospital IT implementations in the UK when it switches over to a new Cerner Millennium system, to be run across five hospital sites, and initially be used by up to 4,000 staff. Newcastle is understood to be installing a fuller version of the Cerner Millennium product than the simplified version of the system bought under the NHS IT programme. Plans for a go-live on August Bank Holiday go-live at Newcastle were put on hold, and a revised late October go-live was also pushed back. Sources close to the trust say it has taken time to work through a series of problems, but is now sufficiently confident to attempt a go live. In testing, problems are thought to have been identified around reporting on 18-week waits, similar to those previously experienced at trusts including Barts and the London. Sources also indicate that up until last week staff involved had only received verbal instructions to prepare for this weekend’s go-live date "due to concerns about any problems and slippage". One NHS source close to the project told EHI the project was going "exceptionally well". Once switched on the Cerner Millennium system will be used for order communications, initially for inpatients with outpatients to follow. Another EHI reader claimed the trust is suffering from "the same problems that have been experienced by other sites exposing the fact that the McKesson legacy system has more functionality suited to the way the NHS works". In August the trust decided to take more time to make sure the switch to the new system did not disrupt business processes. . . The care records system is being installed outside the NHS National Programme for IT in the NHS, under an April 2008 deal with University of Pittsburgh Medical Centre (UPMC). The delays are understood to be causing growing anxiety among UPMC staff, who are keen to move on to their next project at Royal Berkshire, which has also contracted to take Cerner outside NPfIT, in deal involving UPMC and Newcastle. UPMC is thought to have about 25 staff on site working on the Newcastle implementation project, these are currently "free" to the trust and not covered by a subsequent support and maintenance agreement. The trust plans to go-live with the new Cerner Millennium PAS. This will include admission, discharge and transfer summaries, booking and scheduling of theatres and Choose and Book. Eventually the implementation is planned to cover the whole trust, 1,500 beds and 11,000 staff. At the time of going to press, the trust had yet to respond to questions about its planned go-live date.
Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method
Milbank Quarterly 87,4 (2009)
Trisha Greenhalgh et al
Conclusions: The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research.
Fixing NHS IT: How to save £1Bn and get IT working for patients (22 March 2010)
An incoming Government could save at least £1 billion by realigning the troubled NHS computer programme and boosting its performance, according to a detailed new study from a leading health think-tank. 2020health.org have compiled an unprecedented dossier gleaned from extensive interviews with key participants of what has worked, what should be stopped and what next. . . This study, conducted by 2020health.org and written by NHS IT expert John Cruickshank, warns of a risk of "hiatus" for NHS IT after the election expected in May. It is based on confidential interviews with NHS officials and the private contractors tasked with upgrading NHS IT. Key recommendations:
- Future national IT approaches should only be done in limited circumstances. Trusts should be free to set their own direction to meet local clinical priorities, provided nationally agreed standards are met.
- A course of national action and investment is needed in areas where IT is currently under-exploited in the NHS, notably telemedicine and collaborative technology, which are a focus in other countries such as in Scandinavia
- Those elements of NPfIT which are a valuable platform for the future should be developed. These include N3 (the NHS broadband network), PACS (the capture and communication of radiological and other images) and the Electronic Prescription Service.
- Action should be concentrated on addressing the care records service in acute hospitals where the failings are greatest. A series of tests are proposed and a plan of action should the model fail those tests.
- The roll-out of the controversial Summary Care Records project (part of the NHS Spine) should be halted and subjected to review.
- A radical reorientation and downsizing of the central IT organisation is needed for it to become more transparent and accountable to the NHS, in combination with a consolidation and strengthening of IT provision at the local level.
2,500 Newcastle staff using Millennium (14 May 2010)
Newcastle Upon Tyne Hospitals NHS Foundation Trust has completed the roll-out of the Cerner Millennium medicines management system across the Freeman Hospital. The trust went outside the National Programme for IT in the NHS to contract for a University of Pittsburgh Medical Centre implementation of Millennium. It went live with the first elements of the system six months ago and has since been extending it across its three main hospitals. There are now more than 2,500 staff accessing the system at an average of four times a day, and Cerner and UPMC are no longer on-site. The trust started the medicines management roll-out at the beginning of December in a 30 bed nephrology inpatient ward, and has now deployed the system across 27 wards at a rate of 2-3 wards per week. On a visit to the trust earlier this week, Steve Leggetter, e-records programme director, told E-Health Insider: "We've been going live with three wards a week, looking at the medicines charts patient by patient and then working with the project leaders and pharmacists ward by ward." The is still using its McKesson PAS in 'enquiry only' format for a number of staff. It is also continuing to use some paper process alongside electronic medicines management until two remaining speciality areas, ICU and paediatrics, have gone live with the system. This is likely to happen over the summer. The trust has also completed the roll-out of order communications at the Freeman and started implementing the system across the Newcastle General Hospital earlier this week. It will go live with order communications and medicines management at the Royal Victoria Infirmary over the summer and will implement functionality to allow electronic signatures on results. "There is a six week point from where we make the decision to roll out and go-live to actually doing it in terms if readiness and getting training sorted," Leggetter said.