Other Documents

From Nhs It Info

Revision as of 13:34, 17 January 2007

Implementing Information for Health: Even More Challenging Than Expected (10 Jun 2002)

School of Health Information Science, University of Victoria

http://hinf.uvic.ca/archives/Protti.pdf

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. . ."

Article by Robin Guenier (25 Jul 2002)

"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? . . ."

Green Book, Appraisal and evaluation in central government (16 Jan 2003)

HM Treasury

http://www.hm-treasury.gov.uk/economic_data_and_tools/greenbook/data_greenbook_index.cfm

"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.]

New NHS IT (Feb 2004)

Parliamentary Office of Science and Technology

http://www.parliament.uk/documents/upload/POSTpn214.pdf

"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)

http://www.connectingforhealth.org/resources/cfh_aech_roadmap_072004.pdf

"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. . ."

‘That’s How The Bastille Got Stormed’: Issues of Responsibility in User-Designer Relations (17 Mar 2005)

Proc. 5th DIRC Research Conference, Edinburgh

http://www.dirc.org.uk/publications/inproceedings/papers/115.pdf

"This paper presents data and analyses from a long term ethnographic study of the development of an electronic patient records system in a UK hospital Trust – TA ‘Dependable Deployment’. The project is a public private partnership (PPP) between the Trust and a US based software house (USCo) contracted to supply, configure and support their customizable-off-the-shelf (COTS) healthcare information system in cooperation with an in-hospital project team. We use data drawn from our observational studies to highlight a range of responsibility issues in designer-user relationships." [Martin & Rouncefield]

The Spine, an English national programme (25 Mar 2005)

Ringholm White Paper

http://www.ringholm.de/docs/00970_en.htm

"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."

Transformational Government: Enabled by Technology (Nov 2005)

Cabinet Office Report

http://www.cio.gov.uk/documents/pdf/transgov/transgov-strategy.pdf

". . . Information Assurance: despite the difficulties of a fast moving and hostile world, underpinning ITsystems must be secure andconvenient 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 tosupport this model in practice, withan 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 awider availability of assured products and services. . . Identity Management: government will create an holistic approach to identity management, basedon a suite of identity management solutions that enable the publicand 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 thepractical and legal issues of making wider use of the national insurance number to index citizenrecords asa transition path towards an identity card."

OpenEHR (10 Feb 2006)

Informatics Review

http://www.informatics-review.com/wiki/index.php/OpenEHR

"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."

System Design Or Social Change (6 Apr 2006)

Parliamentary IT Committee (PITCOM) on the subject of Public Sector 'IT' procurement

http://www.pitcom.org.uk/reports/Malcolm-Mills-talk.doc

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

http://www.e-health-insider.com/tc_domainsBin/Document_Library0282/NPfIT_guidance_Final_120406.pdf?

". . . 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)

Computing

http://www.computing.co.uk/computing/analysis/2156832/nhs-chief-meets-criticism-head

"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)

Sunday Telegraph

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/06/04/nhs04.xml

". . . 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)

e-Health Insider

http://www.e-health-insider.com/news/item.cfm?ID=1949

"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.)

http://www2.cantabgold.net/users/m.y.becker.98/publications/becker06ijmi.pdf

". . . 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. . ."

Plundering_The_Public_Sector

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

http://www.cbronline.com/article_cbr.asp?guid=35AC0F09-6C33-4D0E-AC2C-D912E2AA6042

"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

http://europa.eu.int/information_society/activities/health/docs/publications/ehealthimpactsept2006.pdf

"An assessment of the economic benefits of implemented eHealth solutions at ten European sites."

Dying for Data (Oct 2006)

IEEE Spectrum

http://www.spectrum.ieee.org/oct06/4589

"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)

Computer Weekly

http://www.computerweekly.com/Articles/2006/10/02/218832/%e2%80%98Gung-ho'+attitude+scuppers+public-sector+IT+projects.htm

"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)

http://www.newstatesman.com/pdf/itmodernisation2006.pdf

New Statesman

"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."

The Common Framework: Overview and Principles (5 Dec 2006)

[US] Connecting for Health

http://www.connectingforhealth.org/commonframework/docs/Overview.pdf

"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)

BBC

http://www.bbc.co.uk/radio4/news/anyquestions_transcripts_20061222.shtml

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

http://www.royalsoc.ac.uk/displaypagedoc.asp?id=23269

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)

e-Health Insider

http://www.e-health-insider.com/tc_domainsBin/EHI_Reports0332/e-health_PAS_Exec_Summary.pdf

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."

The Dossia Consortium (2 Jan 2007)

Account by Geoff Sampson of an American online patient-information service.

Transformational Government: Annual Report 2006 (Jan 2007)

Chief Information Officer Council, Cabinet Office

http://www.cio.gov.uk/documents/annual_report2006/trans_gov2006.pdf

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.