Standards open up border crossing

England and Scotland are sharing information in some instances but they are still few and far between, according to Ken Robertson, clinical lead for IM&T in Scotland.

He gave a presentation at HC2007 on where Scotland and England are already collaborating, future prospects and the necessity of standards. Helen Boddy reports.

Ken Robertson 'The reality is that there is very little information being shared at the moment,' said Ken Robertson. Even in Scotland, which is a small place, passing information across boundaries of the different stakeholders is a complex business.

Ken explained that Scotland has Community Health Partnerships (CHPs) and within each of those there are several GP practices.

CHPs have boundaries, which often overlap. Health boards have several CHPs and several boards constitute a region, of which there are three.

At the moment Ken believes UK collaboration is an uneven game 'with the English elephant sitting on the blind Scottish mouse'. Nevertheless he believes progress is being made.  

The bottom line needed for information sharing has changed little, according to Ken, since he spoke at the same conference in 2005, when his list of the bottom line for data sharing was:

  • GP records;
  • Prescriptions;
  • Data sets for:
    - benchmarking;
    - clinical governance;
    - WHO and other government purposes.

'Prescriptions are one of the currencies of the health service and it would be nice if patients were able to encash prescriptions wherever in the UK they were given them,' he elaborated.

'And we also need to be able to exchange information to cover benchmarking and clinical governance (which of course is very much to the fore).'

Ken added one more bullet point - allergies and updates - to his 2005 list as that is 'now very much in the landscape'.

The extent to which information is shared between England and Scotland varies. On demographics, Scotland has an agreement in principle with NHS Connecting for Health that English patients can use their NHS number in Scotland and Scottish patients the equivalent CHI number in England.

There is no duplication because of the way the numbers are allocated. 'However, that is as far as it goes,' said Ken. 'Scotland is under some pressure to consider the use of the Spine service again, which may have considerable advantage, but the devil will be in the detail, as they say.'

In Scottish general practice, GPEX has in the past allowed an exchange of an extract of information from one practice to another, according to Ken. The GP2GP system has now been used a little in Scotland and he expects it to increase.

Scotland has just completed a pilot of the Document Scanning System (Docman) Transfer, which allows the exchange of scanned documents (bitmap images).

'In the past there has been a lot of talk about data exchange but perhaps we should start with information exchange for care and then move onto data exchange,' he said.

As the Requirement for Accreditation (RFA) process has been scrapped, Scotland uses an advanced functionality programme to keep suppliers up to speed with what is considered important, for example contributions to the Emergency Care Summary.

Through the Scottish Care Information (SCI) Gateway (a national system that integrates primary and secondary care systems using familiar and highly secure internet technology) there are still exchanges across borders from Dumfries to Carlisle, which Ken rates as 'going fairly well'.

The Scottish way of joining up community and GP information systems is through procurement of the Information for Primary and Community Care (IPACC) system. At the moment procurement is being scoped to allow real collaboration between community and GP systems.

'The Emergency Care Summary has been rolled out across the country and now Connecting for Health is copying us,' said Ken. It contains certain drugs, repeat prescriptions and allergies and contact details.

It works on the consent model - implied consent for extraction of information from general practice but explicit at time of access, unless the patient is unconscious, and that is heavily audited.

'I think that less than 100 out of 5 million patients have opted out of it,' said Ken when questioned.

Moving onto the impact of the business model and payment by results, Ken claimed it is not helping collaboration because of putting too much emphasis on bean counting. From a clinical perspective, the lack of clarity around what is happening with the care record service makes it difficult for us to collaborate properly.

In terms of drugs, Scotland like England has been piloting electronic transfer of prescriptions (ETP) and a hospital electronic prescribing and medicine administration (HEPMA) systems. Scotland is in the process of refining requirements for HEPMA and will go the market for a pan-Scotland HEPMA system. Scotland is also procuring a system to support chemotherapy.

'I know these are being paralleled south of the border but there isn’t really any great effort to align that work,' Ken said. 'But we are aligned on the Dictionary of Medicines and Devices.'

On clinical data standards, Ken said that Scotland has 45 clinical standards, which are extensive, and a health and social care dictionary with more than 3000 items.

Scotland is represented on the NHS Information Standards Board, but much of its work is around messaging and high level auditing, which Ken described as 'depressing'.

Scotland has been cited in the development of the common user interface. 'This is interesting, exciting and essential but we shall have to wait and see what emerges from it,' said Ken.

The major Scottish vehicle for delivering clinical information standards is the generic clinical systems toolset. Scotland now has live substantiations for cancer and mental health.

Perhaps the biggest change in terms of standards in the NHS, according to Ken, is the realisation that concentration just on SNOMED CT is not enough.

'The interest in HL7-CDA [Health Level Seven Clinical Document Architecture] is encouraging because it does look as though we are going to pay some attention to the rich information that we have and if we can file it in such a way that it is at least reusable and shareable,' he said. 'I think there is real scope for collaboration across the UK in this area.'

HL7 is one of several American National Standards Institute (ANSI)-accredited Standards Developing Organizations operating in the healthcare arena.

On SNOMED CT Ken hoped that something would happen to solve implementation issues. 'At some point we are actually going to decide we are going to eat this elephant because we have to convert, especially in primary care, a huge amount of data, and that's not going to be a small task,' he said.

In conclusion, Ken said: 'I think it is abundantly clear that we are not going to have the same systems, but we might have some the same. We will therefore be dependent on standards. I think there is no doubt that we could collaborate better across the UK, but the hard bit is that a great deal of common sense is required to do so.

'I think that it’s time that the clinical community takes ownership of this problem. I genuinely don't believe that the technical architects can help us unless we give them a clear steer of what we need. In this regard, I think there is a clear role for the professional bodies who will also be involved in helping to mandate standards.'