Other Documents

From Nhs It Info

Revision as of 17:11, 7 December 2007

Research Challenges in Emergent e-Health Technologies (6 Jul 2001)

Department of Computer Science, Australian National University

http://www.anu.edu.au/people/Roger.Clarke/EC/eHlthRes.html

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

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? . . ."

Why general practitioners use computers and hospital doctors do not (2002)

BMJ 2002;325:1086-9

http://www.bmj.com/cgi/reprint/325/7372/1086.pdf
http://www.bmj.com/cgi/reprint/325/7372/1090.pdf

"Summary:

• 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)

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.]

HIPAA Compliance and Smart Cards: Solutions to Privacy and Security Requirements (Sep 2003)

Smart Card Alliance

http://www.martsoft.com/reference/healthcare/HIPAA_Compliance_and_Smart_Cards_FINAL.pdf

"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."

Electronic Medical Records for the Department of Health Services (2003)

Dan Essin

"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

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. . ."

Current EHR Developments: an Australian and International Perspective (1 Sep 2004)

Health Care and Informatics Review (New Zealand)

http://hcro.enigma.co.nz/website/index.cfm?fuseaction=articledisplay&FeatureID=010904
http://hcro.enigma.co.nz/website/index.cfm?fuseaction=articledisplay&FeatureID=020904

"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

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."

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

http://www.radcliffe-oxford.com/thenhsitproject/br-ch15.pdf

". . . 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

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."

Review of Shared Electronic Health Record Standards (20 Feb 2006)

National E-Health Transition Authority (Australia)

http://www.nehta.gov.au/index.php?option=com_docman&task=doc_download&gid=68&Itemid=139

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

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."

Safer IT in a safer NHS: account of a partnership (Sep 2006)

British Journal of Health Care

http://www.bjhc.co.uk/issues/v23-7/v23-7baker.htm

"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)

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."

Problems abound for Kaiser e-health records management system (13 Nov 2006)

Computer World

http://www.computerworld.com/action/article.do?command=viewArticleBasic&articleId=9005004

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

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.

The Information Commissioner's view of NHS Electronic Care Records (18 Jan 2007)

The Information Commissioner's Office

http://www.ico.gov.uk/upload/documents/library/data_protection/introductory/information_commissioners_view_of_nhs_electronic_care_reco%e2%80%a6.pdf

"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

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.

IT in the NHS: National or Local Design (Jan 2007)

The Bayswater Institute [Powerpoint lecture (with notes) by Ken Eason.]

http://www.bayswaterinst.org/downloads/Local%20Design%20Lecture%20Jan%202007.ppt

". . . 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

http://npa.journalistpresslounge.com/npa/uploads/news/Patient%20Care%20Records%20Community%20Pharmacist%20Access%20to_Jan07.pdf

"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).

http://www.telegraph.co.uk/core/Slideshow/slideshowContentFrameFragXL.jhtml?xml=/news/2007/02/12/nhs/nhspix.xml&site=

"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

http://www.latimes.com/technology/la-fi-kaiser15feb15,1,5401753,full.story?ctrack=1&cset=true

"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)

IEEE Software

http://www.computer.org/portal/cms_docs_software/software/content/promo/s2012_07.pdf

"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]

Computer Weekly's campaign for NHS openness awarded (14 May 2007)

Computer Weekly

http://www.computerweekly.com/Articles/2007/05/14/223903/computer-weeklys-campaign-for-nhs-openness-awarded.htm

"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)

Computer Weekly

http://www.computerweekly.com/Articles/2007/06/25/224998/nhs-it-an-open-letter-to-gordon-brown.htm

"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

http://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC003810

"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)

CIO

http://www.cio.co.uk/concern/alignment/features/index.cfm?articleid=351

". . . 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)

e-Health Insider

http://www.e-health-insider.com/news/item.cfm?ID=2854

"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

http://www.computerweekly.com/blogs/tony_collins/2007/08/the-information-commissioner-r.html

"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)

http://www.palgrave-journals.com/jit/journal/v22/n3/full/2000104a.html

". . . 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)

http://www.palgrave-journals.com/jit/journal/v22/n3/full/2000106a.html

"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)

http://www.palgrave-journals.com/jit/journal/v22/n3/full/2000103a.html

". . . 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)

http://www.palgrave-journals.com/jit/journal/v22/n3/full/2000102a.html

"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)

http://www.palgrave-journals.com/jit/journal/v22/n3/full/2000100a.html

"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)

http://www.palgrave-journals.com/jit/journal/v22/n3/full/2000101a.html

"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)

http://www.kingsfund.org.uk/publications/kings_fund_publications/our_future.html

". . . 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. . ."