We Need to Take Really Radical Steps

Thursday 21 November 2002

The Board Room, Moorfields Eye Hospital, City Road, London, EC1V 2CD

There is a widespread view that use of technology has improved greatly over the last ten years as seen in the impact of the Internet and the requirement for effective corporate information systems dominating the commercial world. The NHS, however, appears to have been left behind. A worthy strategy, 'Information for Health', was insufficiently resourced and a new, more centrally driven version 'Delivering 21st Century IT' is at least a year off making a difference. Why do we appear to have got it so wrong? Perhaps more radical steps should be considered. Two speakers were invited to help us in considering alternative approaches:

Paul Johnson, John Radcliffe Hospital

e-Health: is use of technology to place the individual at the centre of our vision and has a number of aspects. The most important is the arrival of the 'informed patient' with access to and use of information at the right time and in the most appropriate way for that individual. Another aspect is better use by healthcare professionals of evidence to inform the development of management of clinical care. Monitoring of medical conditions is also open to transformation through cheaper and less obtrusive equipment, and use of telemonitoring. This allows measurement in the individual’s normal habitat, the home and work place, rather than in the hospital, and for longer periods. These opportunities illustrate how technology will allow the medical model to be turned upside down with the informed individual placed in the centre.

The informed patient: The increase in use of the Internet by people to seek information on illness and health is a common experience of healthcare professionals. Patients and their carers arrive with bundles of information about their condition printed from the web. How should professionals respond to this? Paul suggested that there needs to be a far greater co-ordination of intervention in terms of education. Professionals within the formal sector need to work with the patient and carer.

For patients who feel excluded from society, other approaches are required. In Britain, an example of an issue is the rate of teenage pregnancy, which continues to be one of the worst in Europe. Present approaches are failing to improve the situation. Paul described a community-based project in which young pregnant women can be monitored in familiar environments and learn about pregnancy together in an informal way. As part of this project they are preparing a glossary of medical terms in their own idiom and publishing this on a web site. Professionals are addressing health needs of the excluded though use of technology intended to bring about changes of behaviour.

Professional use of the evidence base: A paradox is the slow speed of change of professional practice in some clinical areas despite the greater ease of access to information in electronic formats. It is as if we are going into the Information age without using the rapidly expanding evidence effectively. Perinatal mortality rates in Cuba are better than in the US and Britain - why? Unexplained perinatal deaths are known to be related to slow growth of the foetus. In the US and Britain monitoring of the foetus is the norm and yet although circadian rhythms are known in the foetus, this is not taken into account when monitoring takes place. It may be better to undertake such monitoring over a longer period and in the home. We find it difficult to identify individual cases where problems are likely, and then to focus attention on women with the greater risk.

Reversing heart disease: Paul described another clinical area in which new ways of monitoring and more appropriate, non-invasive interventions can be combined to considerable effect. For heart disease, it is better to set up monitoring over a 24-hour period. Then, for patients with proven heart disease, combinations of changes in diet, exercise, and lifestyle have been proven to be as effective as surgery for some cases. Are we focusing on these low cost approaches based on empowering the patient? How should healthcare be conceived and organised to bring about such a focus?

Paul suggested that radical change in medicine must occur. At the two ends of life, when medical intervention is usually concentrated, more continual and sequential monitoring, with intelligent systems triggering interventions, should produce improvement in outcomes. The rise of e-health is unstoppable. We should seek to understand and use it to best effect.

Q Is it always better to have more information about a patient than less?

A Yes, as long as an effective context exists. There can be prompts for the significance of particular hazards through the application of more complex, automated logic in support systems.

Q There are known examples of self care (e.g. for Diabetes and Heart Disease) in which tasks are badly done by some patients - what do you make of this?

A For some people, the provision of information is not sufficient to bring about change in behaviour and engender positive habits of self-care. To bring about change, a context for communication may have to be found that is appropriate to the individual and makes participation more likely. Language is important in this.

Q How do medical colleagues respond to these views?

A Doctors on the whole don’t receive this message well perhaps because of their vested interest in the medical venture and its perpetuation. At the same time, it is as if patients and nurses are already in collusion to make this change of focus come about.

The second speaker was David Kwo

David has just been appointed as Chief Information Officer for London, having previously been seconded to the NHS Integrated Care Record Service (ICRS). David outlined the new approach being adopted for the purchase and implementation of ICT infrastructure and corporate applications across the NHS in London and the rest of England.

David explained that four ICT pillars underpin the present drive to modernise the NHS:

  • Broadband networks.
  • Use of direct booking systems by GPs into Hospital services while the patient is in the surgery.
  • Electronic prescribing within the Hospital and between the GP and the high street pharmacist.
  • Purchase of an Electronic Record - now called the Integrated Care Record Service.

Money will back this relaunch of strategy, with £400M to be available in 2003/4, and £700M and £1,200M over the succeeding two years across England. A small number of Prime Service Providers (PSPs - organisations leading consortia of suppliers) will be selected nationally to provide the ICRS and London will have a single PSP. Finally, the new layers of management, the Strategic Health Authorities (StHAs), of which there are 5 in London, will each have Chief Information Officers who will be responsible for managing the relationship with the PSP. David gave four scenarios to illustrate his thinking of what options lay ahead for progress of the implementation of the PSP across London and elected one of these as a radical approach for discussion tonight:

Electronic Health Record: Placed as a data repository by the PSP, it receives clinical data from the separate systems of hospitals and GPs which is then available for browsing by all. The problem with this approach is that, although it provides access to information, it does not support transactions across the separate systems.

Best of breed: Accumulated by the PSP selecting from different suppliers, who provide the best functions in the different clinical areas, and which are then integrated through a series of interfaces. How much cost and time would this approach take to implement, and is it really practical?

Accreditation of output and input: Legacy systems would be used but modified to ensure a common output and interface. Again, is this possible or practical?

Single system and one supplier: A single enterprise would re-engineer the entire functionality of ICRS across all clinical environments in one system for all healthcare organisations in the area. This was the radical approach David asked participants to consider.

To illustrate the potential for technology to transform the NHS, David showed a video of Visicue, an American development in which remote clinical management of a number of ICU units is supported through telemonitoring and video cameras. Here use of technology offers improved quality of care and lower costs of scarce resource of clinical xpertise.

Q For hospitals already having a developed EPR function, what is the benefit of migration, particularly as there will be extra costs, and less specific tools available to clinicians?

A Any migration to the ICRS will take 5 - 10 years. In this timescale most existing EPRs will need replacement. Local EPR can serve individual organisations well but as a whole the health community has a fragmented set of records and functions and this should not be perpetuated.

Q The best place for the patients record is in the home and the EPR has one purpose within a medical environment - to enhance the patient’s treatment.

A Supporting the informed patient is an essential requirement for the ICT services of the NHS. The EPR must support the wider care pathway across separate medical environments rather than in isolated ones. For this to happen, my view is that a single system shared across clinical environments is a necessity.

Q Is there not a danger of extending the EPR beyond the ability of anyone to use it effectively? The EPR may support the medico-legal venture better than the patient.

A Current systems are not well used by clinicians and this has to be addressed. Across 28 acute hospitals there are currently 11 different EPR systems and this fragmentation cannot be good for patients, although it may benefit some clinicians. The rise in the number of legal cases associated with medical practice is regrettable and I would suggest not directly related to the presence or absence of good information systems.

Q Perhaps we need to rethink the concept of the EPR from being a composite record of care for the patient to being functions and services to be delivered to patients by different agencies, i.e. scheduling as a linking concept as happens with the airline, hotel industries and stock exchanges.

A We need to use existing information flows and services to better effect at the same time as progressing with the ICRS.

Q Won’t the selection of a small number of PSPs depress innovation in the market?

A We need to figure out a way to manage the market so that there is true competition for the benefit of the NHS and the patient. This will be difficult but the present market is already dominated by a small number of large suppliers who are not, on the whole, innovative.

Q The ICRS specification documents lay out a requirement for functional integration with social care. What will the PSP mean for the present 33 Social Service department and the possible successor Trust organisations formed with the NHS?

A It is essential that each implementation of the ICRS is local in focus and managed by a multi-disciplinary and multi-agency team with Social Service included.

Q Taking the example of Visicue, the importance of the 'front-end' of systems for the clinician and user will become very important - rather like the control panel of atomic power stations.

A Visicue does not use complicated technology and is a proven solution.