I T N Newsletter

Information Technology in Nursing 18 (1)
1
Volume 18 Issue 1
March 2006
The official journal of the
Nursing Specialist Group
ISSN 0956-5159
I
T
I
N
Newsletter
Editor: Nicholas Hardiker
Chair’s Update
Richard Hayward
This has been a busy period for the NSG. A survey of members’ needs and hopes for the group was carried
out at the end of September last year, and may I thank all members that participated The main conclusions
were that the group offered members three significant benefits:
• Networking and contact opportunities
• Face-to-face meetings
• A hard copy journal.
Through our regular seminars and workshop sessions we successfully achieve the first two listed, however,
as you already know, there have been difficulties in fully realising the journal. The Executive have entered
into discussions with Sage Publishers to consider combining ITIN with the Health Informatics Journal. As
part of the ongoing discussions, I need to know how many of the membership already have a subscription to
the HIJ. If you could e mail me at [email protected] if you have a personal subscription to HIJ I would
be very grateful.
Whilst these discussions are taking place, the Executive decided to produce this newsletter to keep the
membership up to date with news and events in Health Informatics. I would like to acknowledge the
tremendous job done by Sue Kinn, the news editor in keeping us informed.
A very successful joint meeting with the Bristol Branch of the BCS was held in Bristol in November attended
by 80 participants. Sean Brennan gave a very humorous and informative talk on the National Programme
based in part on his book, “The NHS IT Project: the biggest computer programme in the world.. ever!”. The
meeting raised the profile of the group in the area and informed participants of some of the developments in
health informatics in general.
A further meeting with the Nursing Clinical Lead, Barbara Stuttle has been arranged for 1st March, 2006
in London to which you would all be welcome. Further details are available on the Web Site
(www.bcsnsg.org.uk).
The group will host a satellite session at HC2006 on 20th March, 2006, 2-3.20pm in Harrogate, preceded
by our AGM at 1pm, Lunch will be provided. I encourage as many members to attend as possible.
© 2006 Health Informatics (Nursing) Specialist Group, British Computer Society
2
Information Technology in Nursing 18 (1)
News
Sue Kinn
White paper outlines IT role in community services
The new white paper Our Health, Our Care, Our Say: A New Direction for Community Services has
outlined a range of proposals for developing use of IT in primary and community care. One of the cornerstones
of the white paper is a focus on prevention and empowering patients to take care of their own health.
Patients will be able to complete an online self-assessment of their health and send it electronically to their
GP to be stored as part of their record. Every citizen will be offered an NHS ‘life check’. An internet site,
HealthSpace, will be available for patient to be able to access their summary record on the NHS Care
Record Service. The summary will also be available on paper for anyone without internet access. Patients
will be able to complete information covering a range of risk factors as well as details of their family history
and store the information online. Those whose initial self-assessment indicates that they are at significant
risk of poor health will be able to discuss the results with a ‘health trainer’.
NHS Life Check will be developed and evaluated in 2006-7 with the aim of wider rollout after that. However
the white paper rules out the idea that patients should carry their medical records on their own smartcards
which it says will not be necessary since the existing proposals for access to medical records through the
NCRS will offer the same benefits.
Another key part of the white paper outlines plans for a demonstration project, covering at least a million
people in a variety of locations, to look at how technology can be developed to keep patients out of hospital
and in the community. Other IT-related projects highlighted in the white paper include proposals to work
with Connecting for Health (CfH) to improve the existing national population-based immunisation reporting
system, to provide support to PCTs to introduce computerised cognitive behaviour therapy and to develop
the Quality and Outcomes Framework by 2008/9 to focus on health outcomes.
The White Paper can be found at:
http://www.dh.gov.uk/assetRoot/04/12/74/59/04127459.pdf
CfH announces awards for health IT innovation
Entries have opened for the 2006 Health Informatics Accolade Scheme, which aim to reward the innovative
use of technology in the NHS for both clinical and non-clinical purposes. NHS Connecting for Health is
offering five prizes of £5000 each for organisations that demonstrate innovation in health informatics.
Projects will be judged by CfH and professional organisations UKCHIP and ASSIST. The theme of this
year’s awards will be “The Clinical and Informatics Partnership”, focusing on shared goals between IT
professionals and clinicians. Judges will be looking for a wide range of projects, both small and large-scale,
as long as they can be demonstrated to illustrate links between informatics and healthcare. The criteria
which judges will consider are value for money, originality of idea, best practice and the benefits to staff and
patients, and entries will also have to explain how the £5000 prize would be spent if successful.
The deadline for entries is 7 April 2006, with prizes being awarded on 16 May, and the competition is open
to everybody in health informatics in all NHS organisations.
For more information go to:
http://www.connectingforhealth.nhs.uk/delivery/serviceimplementation/modernisation/etd/accolade
© 2006 Health Informatics (Nursing) Specialist Group, British Computer Society
Information Technology in Nursing 18 (1)
3
Bush renews call for more use of healthcare IT
In his annual State of the Union address this year, President Bush linked quality, affordable healthcare to US
competitiveness in the global marketplace.
“For all Americans—for all Americans, we must confront the rising cost of care, strengthen the doctorpatient relationship and help people afford the insurance coverage they need,” Bush said. “We will make
wider use of electronic records and other health information technology, to help control costs and reduce
dangerous medical errors.”
This marked the third consecutive year Bush mentioned IT and electronic health records in his State of the
Union. It was during the 2004 State of the Union that Bush challenged the country to create EHRs for most
Americans within 10 years. In all, healthcare got about two paragraphs in a speech that was some 5,300
words long. The IT was embedded into a larger discussion of healthcare policy, showing that it is part of a
broader healthcare agenda.
There is an increasing concern about rising healthcare costs. Major American corporations like General
Motors and Starbucks are spending more on health insurance for their employees than they are on raw
materials for their core products. Actions over the past two years include the establishment of the Office of
the National Coordinator for Health Information Technology and the funding of public-private collaborations
to develop healthcare data standards.
By spring, the US will have a programme for certifying that EHRs for ambulatory care [delivered without a
hospital stay] meet certain minimum standards.
‘Plymouth’ offered as an interim solution
Connecting for Health has shelved plans to provide NHS acute trusts across three regions in England with
an integrated, strategic next-generation clinical system for another two or three years.
Connecting for Health has begun offering some acute trusts in the North East, Eastern and North West and
West Midlands regions, with a need for new systems an interim solution based on existing iSoft systems as
currently deployed at Plymouth Hospitals NHS Trust. The new interim plan is being referred to as the
‘Plymouth’ or ‘Derriford’ option. The need for the ‘Plymouth option’ has arisen because the functionality of
the strategic clinical software has been subject to repeated delays.
CfH, the agency responsible for the National Programme for IT (NPfIT), awarded contracts to LSPs and
their sub-contractors, based on the phased delivery of a next generation clinical solution provided through
five progressively more sophisticated software releases up to 2010 – each one adding new clinical capabilities.
In the North West and West Midlands, North east and Eastern regions - where iSoft was sub-contracted to
deliver a next generation clinical system – this incremental release strategy now appears to have been put
on hold. This means that for some of the Trusts all that is available is a basic PAS.
This poses problems for the trusts as the system is said not to be fit for purpose. Trusts will require far more
sophisticated tools such as tracking of patients, order communication, care pathways, intelligent rules-based
ordering and reporting of pathology and radiology. Other Trusts have also expressed similar concerns as
reasons to shelve the local LSP systems until it is fit for purpose.
© 2006 Health Informatics (Nursing) Specialist Group, British Computer Society
4
Information Technology in Nursing 18 (1)
Choose and Book target now March 2007
The target date for the implementation of Choose and Book has been moved back again, this time to March
2007. Margaret Edwards, director of Access at the Department for Health, has written to all strategic
health authorities and primary care trusts, stating that the requirement for 90% of GP referrals to be booked
through Choose and Book has been put back to March 2007, from December 2005.
The plan to include referrals from dentists in the targets has also been dropped. In November Sir Nigel
Crisp, NHS chief executive told the Public Accounts Committee that Choose and Book was running about
12 months late. The letter outlining the extra three months for PCTs and SHAs is accompanied by more
interim targets on Choose and Book. The acute trusts that are not able to implement an integrated patient
administration system for Choose and Book are expected to ‘go live’ with indirectly bookable services (IBS)
in all specialities by the end of March this year. IBS is a standalone fix that allows acute trusts whose PAS
systems are not compliant with Choose and Book to make electronic bookings.
PCTs will be expected to submit monthly trajectories on their progress towards the March 2007 deadline
and will also still be able to claim the third incentive payment from the original Choose and Book incentive
scheme which offers £100,000 if PCTs achieve 90% booking through integrated booking, not IBS, by December
2006 at the latest. There are a small number of trusts that for valid technical/ commercial reasons will not
be able to achieve a fully compliant integrated solution during 2006. These organisations will have explicit
exemption agreed with NHS Connecting for Health (CfH) but will still need to achieve 90% via IBS. Only
one PCT, Durham Dales, was able to claim the first incentive payment for achieving 50% of bookings
through Choose and Book by the end of October 2005 and none met the December target of 80% of
bookings through the service by the end of December.
According to latest Connecting for Health figures a total of 94,637 bookings had been made via Choose and
Book by 24 January. A total of 9.5 million outpatient appointments are booked each year.
GPs say that Choose and Book is not easy to use
The Choose and Book system is “clunky and cumbersome” and slower than the paper-based referral
mechanism it is intended to replace, according to a small survey of GPs, done by the GP magazine Pulse.
Other surveys have also found similar results.
Delays of up to 45 minutes in getting through the screens were reported, and a number objected to too many
keystrokes and steps. GPs have said that Choose and Book’s interface hinders, rather than helps booking
appointments. The user interfaces have not been well received, they are too cumbersome and this can
result in a slower system than the “paper” office they aim to replace. The system has been described as
overcomplicated and training and feedback about the workings of the system have been criticised. The
reliance on pop-up windows has worried some users, who have had to disable blocking software in order to
access the system thus putting the security of their computers at risk.
Connecting for Health has said that several thousand GPs use Choose and Book. Between them they have
already made well over 100,000 bookings through the system. The C&B system had undergone extensive
testing and feedback from users, and from timings of how long it takes to make a booking, show that Choose
and Book is efficient, easy to use and flexible. Timings have consistently shown that Choose and Book
takes an average of 90-100 seconds for an end to end direct booking transaction when the PC and local
networks through which Choose and Book is being used are configured correctly, and the user has been
trained with the application. CfH disagreed that pop-up windows were prevalent throughout the application
and compromised security. Choose and book runs in a ‘kiosk’ window; a normal way to provide increased
security and improved usability for such applications by removing the browser toolbars and navigation buttons.
The initial opening in a kiosk window is the only use of the “popup” technique in Choose and Book.
© 2006 Health Informatics (Nursing) Specialist Group, British Computer Society
Information Technology in Nursing 18 (1)
5
Scottish practices make the case for new IT systems
Scottish GPs are exercising their new right to choose their own IT systems with an exodus from the dominant
GPASS (GP Administration System for Scotland). According to the British Medical Association’s Scottish
GPC IT sub-committee over a quarter of GPASS 880 users have submitted business cases to abandon
GPASS and obtain funding for new systems.
GPs won the right to choose their own systems in April last year following protests about GPASS and a
similar ruling about system choice for English GPs. Certain conditions have to be met including an agreement
that the new system will use a central data server. GPs have coped with a number of problems with GPASS
and were promised a new improved version – GPASS Clinical. At the moment 21 practices have the new
version.
The latest GPASS problem, reported to the BMA Scottish GPC IT sub-committee, is with the CALM
contract manager software that calculates performance under the Quality Outcomes Framework (QOF). A
fault in the software has set to zero the column that records the reminder letters sent to patients needing
reviews for chronic conditions such as high blood pressure or asthma. January was a particularly bad time
for the problem to occur with deadlines looming for the submission of 2005-6 QOF data. A GPASS
spokesperson said that the bug would be fixed by downloading CALM V23.
The speed of the switch to other systems would depend on the capacity of other system suppliers to move
250 practices. More practices may want to move if there were more incidents along the lines of the CALM
problem.
CfH due for restructuring in DH shuffle
NHS Connecting for Health (CfH) has signalled that it will undergo restructuring later this year as part of a
wider reorganisation in the Department of Health. An announcement from CfH, which is currently designated
as an agency of the Department of Health, says that the precise nature of the organisation and of the
associated governance arrangements is being finalised.
A reshuffle at the Department of Health also sees CfH’s chief executive, Richard Granger, join the
Departmental Board from 1 February. The arrangements are being portrayed as ‘transitional’.
In his announcement of the changes ‘Creating Tomorrow Whilst Managing Today’, NHS chief executive,
Sir Nigel Crisp, said that 2006 is an important transitional year for the NHS as reforms to the system
continue. There is a job change for the agency’s senior responsible owner (SRO) and chair of the National
Programme for IT’s governance board, John Bacon. He will stay in his CfH roles, however, until the new
arrangements are in place.
As part of the general reshuffle, Bacon is being moved from his current post as DH group director for
delivery to take up a transitional leadership role for the NHS in London. Bacon has chaired the NPfIT board
since March 2004. The national SRO post has been through several changes of ownership, as have some of
the regional SRO positions. The Office of Government Commerce recommends that one clear SRO should
oversee any complex project to maintain continuity and focus.
In general, though, the message from CfH seems to be that it’s ‘business as usual’. The agency said: “CfH
and its people remain focussed on building on the foundations that have already been laid to bring about an
IT-enabled NHS. These foundations have seen deployments of new IT systems and networks to thousands
of locations and which are already benefiting millions of patients.”
The departmental changes also see the roles of director of access and director of performance axed and
replaced by two new posts: director of commissioning and director of provider development.
© 2006 Health Informatics (Nursing) Specialist Group, British Computer Society
6
Information Technology in Nursing 18 (1)
Public-private venture to improve access to information
Dr Foster, a commercial provider of healthcare information, and the NHS Health and Social Care Information
Centre have formed a new public-private partnership with the aim of improving public access to information.
The new venture will be called Dr Foster Intelligence, which will combine commercial acumen from the
private sector with the specialist expertise and commitment of the public sector.
The announcement of the new partnership was short on detail of the specific projects the two parties have
in mind. The partnership will draw on the strengths of both organisations; the new venture will combine Dr
Foster’s existing health related business with the Information Centre’s existing analytical services. A number
of Information Centre staff will be seconded to Dr Foster Intelligence.
The company will launch operationally on 13 February when more information about Dr Foster Intelligence’s
planned products and services will be unveiled.
The partnership between the Health and Social Care Information Centre and Dr Foster will help to establish
an information market which will empower managers, frontline staff and the communities they serve. The
key beneficiaries will be the public.
New medical students to face computer test
Many students applying to university to study medicine or dentistry will be required to undergo a 90-minute
computer aptitude test as part of their course application.
The UK Clinical Aptitude Test (UKCAT), which is being developed by a consortium of universities with
testing company Pearson VUE, will affect students applying to 24 medical schools nationwide. Students
will be able to book the test online, choosing to take it in one of 150 centres over a two and a half month
period.
A very large number of people apply for medicine and dentistry every year, about 40% of the people who
apply will get in, out of something like 16,000 – 17,000 applications per year.
The UKCAT will feature verbal reasoning, numerical reasoning, abstract reasoning and problem solving
questions; it will not cover academic subjects. The exam will not necessarily have a pass mark, but results
will be used by each medical school as part of the overall assessment of the candidate.
There are advantages for the test being carried out on a computer - the test is generated from a large bank
of questions, from which students can practice. Results can also be processed quickly.
The UKCAT will assess a wide range of general skills and attributes rather than strictly academic achievement
and will assist universities in creating a level playing field for applicants from diverse educational and cultural
backgrounds.
The test will not be completed online, candidates will need to travel to exam centres for reasons of
confidentiality and because it needs to be completed under exam conditions. It will not be the type of test
that you can prepare for.
The tests will start this summer, for candidates hoping to enter medicine or dentistry schools in 2007. An
additional section covering behaviour is currently being developed.
© 2006 Health Informatics (Nursing) Specialist Group, British Computer Society
Information Technology in Nursing 18 (1)
7
Germany to trial electronic health cards
Germany is to start trialling an electronic health card at the end of April that will contains basic patient data
such as name, age, next of kin and insurance details, as well as electronic prescriptions.
The Gesundheitskarte (‘good health card’) will contain information in a Chip-and-PIN style microchip on
the side of the card, as well as a photograph and human-readable information. It replaces Germany’s existing
health insurance card. The back of the card will double as a European Health Insurance Card, which
replaced E111 forms at the start of the year for all EU citizens and will enable all holders to receive healthcare
in other countries in Europe. Electronic prescriptions can also be issued using the card. A GP can upload the
prescription data onto a chip in the card and sign it electronically, and the medication data can be read at the
pharmacy. For security, there is a signature strip on the back of the card that the pharmacist must validate
before handing over medication. The German health ministry already projects that 700 million prescriptions
per year will be issued in this way.
According to the BMJ, patients will also have the opportunity to include their own health information on the
card, and log in via a PIN number. Healthcare professionals, including insurance companies, will need to
use another electronic card to log in and read and change patients’ card details. Testing for health
professionals’ access cards began in December. The federal office for IT security, has stressed that both
the patient and professional cards were crucial to the security of the healthcare informatics system. The
patient’s electronic health card had been scheduled to be in widespread use at the beginning of 2006 but the
programme has fallen behind schedule. If the trial is successful the cards will be expanded to cover 100,000
users by the end of 2006.
More focus on research needed in NPfIT
A report form the Academy of Medical Sciences has stated that medical advances are being inhibited by
unnecessary constraints on the use of patient data.
Leading academic medical researchers say that the Care Record Guarantee currently makes commitments
that, if strictly interpreted would prevent a significant number of research projects from using Connecting
for Health data. The National Programme for IT (delivered through Connecting for Health) offers an
exceptional opportunity to allow research to inform all aspects of healthcare. However the academy is
concerned that that research needs are not being integrated into its development. In particular the researchers
set out their concerns about the Care Record Guarantee and say that the Secondary Uses Service being set
up by Connecting for Health (CfH) has not yet fully considered research requirements
The report recommends CfH should take urgent steps to set up a research advisory group. The authors
contend that famous life-saving research, such as the studies conducted by Professor Sir Richard Doll that
first linked smoking to lung cancer, would not be possible now. However not everyone agrees. For instance
Professor Joan Higgins, chair of the ethics committee of the Care Record Development Board who has
been deeply involved in the development of the Care Record Guarantee, and chair of the Patient Information
Advisory Group said that it is incorrect to say that seminal research, such as that linking smoking and cancer,
could not be carried out today because of excessive regulation.
Legislation specifically allows access to large databases for which the effort of seeking consent from
thousands of patients would be disproportionate. Many of the regulations were designed to protect people
when they are at their most vulnerable: when they are sick and using the services of the NHS. Not all
research is good research. Some of the measures were introduced after the tragedy at Alder Hey hospital.
The key message of the investigation there was that people are often ready to take part in research, but it is
important not to assume consent.
© 2006 Health Informatics (Nursing) Specialist Group, British Computer Society
8
Information Technology in Nursing 18 (1)
Information Commissioner, Richard Thomas, stated that it is wrong for the Academy of Medical Sciences to
blame the Data Protection Act — still less ‘overzealous’ interpretation — for denying researchers access to
essential patient data. The central issue here is patient confidentiality. Since the days of Hippocrates,
medical records that identify patients have been protected by the doctor’s duty of confidentiality. Patients
do not expect our doctors to pass on their medical details to others without their knowledge or consent, even
to medical researchers. Most medical research uses anonymised information. Where named records are
essential, my office stands ready to help researchers to find solutions, which do exist. It is not normally a
problem for patients to be informed about the use of records for research, and for concerns to be taken into
account. The law also recognises that consent is not required in every situation.
The 84-page report covers the legal and governance framework around medical research and looks at the
issues of confidentiality, anonymisation, data security, consent and engaging the public. The report’s overall
theme is that the UK has an outstanding record of medical research based on the use of health information
and has the potential to become a world leader in this area through opportunities offered by the NHS and by
initiatives in the UK countries to develop national care records. But it criticises constraints on the use of
personal health data which are, the reports’ authors argue, inhibiting advances. They say that the constraints
arise through confusing legislation and professional guidance, bureaucracy of process and an undue emphasis
on privacy and autonomy. It is essential that data about the health of individuals are only used for research
under condition of confidentiality that enjoy public support. However, evidence of public attitudes towards
the use of health information in research is largely absent, forcing regulatory and advisory bodies to make
assumptions about what the public might find acceptable.
These factors have created a conservative culture of governance, where disproportionate constraints are
imposed on research that can compromise its quality and validity. Connecting for Health stated that the
electronic care records service will be introduced over the next few years and will create a huge and
valuable resource for research, for improving clinical care and patient safety. It can only do so successfully
if it has the confidence and support of the public who are rightly concerned about the confidentiality and
security of their clinical records as well as supporting properly conducted and ethical research.
The NHS Care Record Guarantee for England sets out the way in which the NHS will collect, store and
share our records, when and how we can limit sharing, when and how we will be asked to consent and what
happens if something goes wrong. This is the first such guarantee published by a government department
and supported by ministers and sets a new standard of transparency and accountability to the public. Far
from obstructing good, ethical clinical research the Care Record Guarantee will support it.
For more details find the report at:
http://www.acmedsci.ac.uk/p47.html
Sources
The information in these news pages has come from a variety of sources including computer weekly (http:/
/www.computerweekly.com), e-health media (http://www.e-health-media.com), NHS Informatics (http://
www.informatics.nhs.uk), the Health Informatics community of the National Electronic Library for Health
(http://www.nelh.nhs.uk), e-health insider (http://www.e-health-insider.com) and Future Health Bulletin (http:/
/www.headstar.com/futurehealth).
More details of the above and many other stories can be found on these websites.
© 2006 Health Informatics (Nursing) Specialist Group, British Computer Society