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HEALTH INFORMATICS NOW is the
newsletter of The British Computer Society
CONTENTS
health informatics community.
It can also be viewed online at:
www.bcs.org/hinow
HEALTH INFORMATICS NOW is a
quarterly publication. The deadline for
Forum
4
Issue round-up by Sheila Bullas, leader of the
BCS Health Informatics Forum editorial board
6
Industry news
8
Patient safety: the contribution of professionalism
10
Patient safety: is it safe to share records locally?
11
Patient safety: safer systems play a vital part
13
HC 2008: Swindells to headline on future strategy
14
Virtual radiotherapy reduces training pressure
15
Putting eHealth into context in Africa
16
Meet the group: BCSHIF Strategic Panel
18
Clinical document sharing supported by standards
20
The NHS23 still favour an independent review
22
Pilot assesses effectiveness of services
26
Forthcoming events
contributions to the June 2008 issue
is 14 April. Please send contributions to
[email protected]
Forum manager
Christine Mayes: 01793 417 635
[email protected]
Editorial board
Sheila Bullas (leader), Keith Clough,
Andrew Haw, Ian Herbert
Editorial team
Editor: Helen Boddy
[email protected]
01793 417 577
Managing editor: Brian Runciman
Art editor: Marc Arbuckle
Graphic assistant: David Williams
Registered Charity No 292786
The opinions expressed herein are not
necessarily those of The British Computer
Society or the organisations employing
the authors.
© 2007 The British Computer Society.
Copying: Permission to copy for educational
purposes only without fee all or part of this
material is granted provided that the copies
are not made or distributed for direct
commercial advantage; the BCS copyright
notice and the title of the publication and its
date appear; and notice is given that copying is
by permission of The British Computer Society.
Read Peter Murray’s HI blog at
To copy otherwise, or to republish, requires
www.bcs.org/blogs
specific permission from the address below
and may require a fee.
Printed in Great Britain by Inter Print,
Specialist and member groups
Swindon, Wiltshire.
ISSN 1752-2390. Volume two, number three.
ASSIST
The British Computer Society
First Floor, Block D, North Star House,
23
North Star Avenue, Swindon SN2 1FA, UK
Events receive boost from coordinator and
commerce
tel +44 (0)1793 417 417;
fax +44 (0)1793 417 444; www.bcs.org
Incorporated by Royal Charter 1984.
Northern
24
Patient access helps avoid another Shipman
03
Round-up of this issue
Sheila Bullas
editorial board leader, Health Informatics Now
secretary, BCS Health Informatics Forum
director, iBeck
Loss of records containing a great deal of personal
information has been a regular feature in the news recently,
including loss of patient records. Whilst the security of large
computer databases is of the utmost importance, recent
events have demonstrated that it is often people that cause
the problem. If people can access a large amount of data, and
distribute it by insecure means, there will come a time when
it falls into the wrong hands or is lost, despite the law,
policies and procedures aimed at providing protection. It is
part of the human condition; it is inevitable. It is also totally
unacceptable. It is against this background that we focus on
patient safety in this issue.
Some commentators point to the fact that the paper
medical record is far from secure – left lying around for
prying eyes. This may be true but misses the point. If all the
patients’ records are in a single place, there is only one place
for those intent on theft to look and, as has been recently
demonstrated, it is not the single record that goes missing, it
can be millions of records going missing in an easily
accessible form. The case for sharing information
appropriately is well supported: improving child safety and
that of vulnerable adults, those will chronic illness and
emergencies outside their local area. But whether the
fundamental issues have been adequately addressed is
considered in an article by Dr. Mary Hawking – see p10. Dr
Amir Hannan, who took over the Shipman practice, recently
spoke at a meeting of the HI Northern Specialist Group, where
he described how he restored patient confidence by opening up
and sharing records with his patients – see article on p24.
If people are a weak link in the security chain, then
professionalism standards in health informatics must be at
least part of the answer. Mik Horswell and Jean Roberts
consider how actions such as registration with the UK Council
04
for Health Informatics Professions (UKCHIP) can make a
difference to patient safety – see p8. Patient safety is also the
subject of the article by Maureen Baker, national clinical lead
for safety, Clinical Safety Team at Connecting for Health – p11.
HC2008: An invitation to the future
As we go to press with this issue of Health Informatics NOW,
the finishing touches are being made to the HC2008
programme: three days of conference and exhibition for
everyone involved in handling and managing information in
healthcare. If you are a clinician, care professional, manager,
IT or information management specialist, there is sure to be
something for you at HC2008 being held 21-24 April
in Harrogate.
Leading figures on the major current issues will be
presenting their work and views. Safety and risk, transforming
services and implementing national programmes are just
some of the topics. Understanding healthcare focuses on the
practice of GPs, GP staff, hospital clinicians and managers. It
explains some of the mysteries including the diagnostic
process, funding and the 18 week target: all areas where ICT
is playing a significant role. Visit www.health-informatics.org
for details of the programme and conference registration or
www.healthcare-computing.co.uk for information
on exhibiting.
Transforming healthcare
In our next issue, the focus will be on transforming healthcare
with reports from HC2008 and a recent BCS Thought
Leadership debate on this topic. If you have something to say
on this topic, send articles to [email protected]
How long before your
IT team fill their skills gap?
- how long
is a piece of string?
(We hear some people say)
Without a defined framework to
measure and develop skills against,
the journey towards greater
professionalism could roll on forever.
The SFIAplus standard (Skills
Framework for the Information
Age) defines the skills needed by IT
professionals plus the training and
development required to maintain them.
Information Governance, Data Protection
and Patient Confidentiality within the
healthcare sector demand ever-increasing
levels of professionalism in IT. Using the
recognised industry standard is critical
for the effective management of the skills
required to demonstrate compliance in
such areas.
Measuring and benchmarking
IT skills within a role
Describing skill requirements
Identifying skill gaps & planning
training activities
Identifying career paths
Define your journey to IT professionalism
www.bcs.org/sfiaplus
For your free wallchart telephone 01793 417541
or email [email protected]
BCS IS A REGISTERED CHARITY: NUMBER 292786
Achieving external validation of IT
professional development schemes
Is Wii little substitute?
A care home in Wales has installed
two Nintendo Wiis to entertain
residents, and provide them with a
mental challenge and physical
exercise. Neath Port Talbot council,
which runs eight care homes, funded
the Wii purchases via a grant from
the Strategy for Older People.
If successful, it hopes to extend
the Wii to other homes and day
services. The councils says evidence
suggests such puzzles could help
halt the progression of Alzheimers.
At the other end of the
spectrum, schools have also been
experimenting to see if the Wii can
encourage children to be more
active. However, one study has
reportedly shown that it is little
substitute for playing ‘real’ sports.
GMC moves into interactivity...
The General Medical Council
(GMC) is using interactive media
for the first time to promote its
ethical guidance to doctors.
On the GMC web zone, ‘Good
Medical Practice in Action’
presents patient consultation and
invites the user to choose how
to address them as per the
GMC’s guidance.
Dr John Jenkins, chair of the
GMC Standards and Ethics
Committee said: ‘We want as many
doctors as possible to evaluate the
scenarios and provide us with
feedback as to how this new
approach could be developed and
made most useful for them.’
...and reviews patient guidance
Electronic patient records are one
key issue for consideration in a
review of the General Medical
Council’s current guidance on
confidentiality.
The first step of the review is an
initial consultation from 14
January to 29 February, which will
include considering disclosing
confidential information for public
protection and secondary use of
patient data for research and health
service management.
06
First prize for accessibility
goes to Johnson’s website
Health secretary Alan Johnson scooped
first prize for accessibility at the BCS
MP Website Awards late last year.
He won one of four categories in the
inaugural BCS MP Website Awards,
which sought to spotlight and applaud
MPs who BCS believes have best used
their websites to passionately
communicate their political platform.
AbilityNet, the national charity that
helps disabled adults and children use
computers and the internet by adapting
and adjusting their technology, assessed
the sites on accessibility.
Other winners were Adam Price
for best website overall, Paul Flynn
for best design and Derek Wyatt
for engagement.
CFH diverts training funds
Two qualifications accredited by BCS
are to form the basis of a new IT
training programme to be funded by
Connecting for Health (CFH).
CFH is centrally backing the new
Essential IT Skills (EITS) Programme,
instead of the European Computer
Driving Licence (ECDL). EITS became
available on 3 March and funding for
new registrants to ECDL is to end on
21 March.
The ECDL service has delivered
320,000 online tests, but a review
carried out in 2007 concluded that the
training needs of the NHS in 2008 had
changed significantly since the
introduction of ECDL in 2002.
The EITS programme addresses
two areas:
NHS ELITE (eLearning IT
essentials) trains staff on basic
keyboard and mouse skills as well as
file management, web and email skills.
NHS Health (eLearning for health
information systems) trains staff in
complying with information governance,
data protection and patient
confidentiality requirements.
Both will be available to all NHS
staff through an NHS BCS Approved
Centre. The CFH funding will cover the
provision of learning materials, testing,
certificates and accreditation for the
duration of the EITS programme.
Candidates will be able to learn in a
classroom with a tutor or online.
The EITS programme has been
developed specifically with users of the
National Programme for IT computer
systems and services in mind. It also
aims to prepare them to use the virtual
learning environment and electronic
patient record systems.
CFH will continue to provide free
access to the existing ECDL learning
materials for ECDL users who are
registered on the portal before 21
March 2008, for one year following
their registration.
CFH is also supporting the
deployment of a new NHS national
learning management system.
Remote A&E for Aberdeen
Patients in north-east Scotland who
live a distance away from an A&E
department can now talk to a doctor
via teleconferencing.
Aberdeen Royal Infirmary in
Scotland is running a trial, in
conjunction with the Scottish Centre
for Telehealth and the NHS for
Scotland, to assess the efficacy of Cisco
HealthPresence technology, as well as
patient and caregiver satisfaction.
The technology interfaces with
medical diagnostic equipment, such as
stethoscopes and otoscopes, as well as
a vital signs monitor that can measure
blood pressure, temperature, pulse rate
and pulse oximetry. An attendant is
available to maintain the technology,
and operate the medical devices on
behalf of the remotely located caregiver.
Swindells and Hextall take
the helm in interim posts
With the departure of Richard
Granger as the director general for
the National Programme for IT in
the NHS on 31 January, the
Department of Health (DH) has
made two interim appointments.
Matthew Swindells has been
appointed interim chief information
officer (CIO) for health. He is on
secondment from the NHS and will
focus on delivering the DH’s overall
IT vision. Swindells is leading an
informatics review.
Gordon Hextall, who has been
chief operating officer in the
Connecting for Health (CFH) team
over the last four years, will act as
the interim director of the IT
programme and system delivery.
He will focus on managing CFH
and enhancing partnerships in the
NHS. The department is putting out
the two permanent vacancies to
open competition.
Lorenzo phased in until 2011
The fourth and final phase of Lorenzo
next generation clinical software system
for the NHS IT programme will not
start to be rolled out by Computer
Sciences Corporation (CSC) until
2009, according to E-Health Insider.
The Lorenzo platform will be
delivered, according to the latest
reports of plans, in four releases,
starting in 2008 for the first roll-out.
The fourth release, which would add
integrated care pathways and an
integrated GP system, should be
available in 2009 at the earliest, with
implementation running into mid-2011.
Development of the software by
iSoft and its delivery is running several
years late. CSC is due to deliver the
software to three-fifths of the NHS in
England, including the North, East
and Midlands.
South Birmingham, Morecambe
Bay and Bradford & Airedale are
preparing to take the first version of
Lorenzo this year.
West Midlands SHA reportedly
believes that the earliest realistic date
for obtaining benefits from a regional
shared electronic records system is
2012, E-Health Insider reports.
3,000 practices use GP2GP
More than 3,000 GP practices are
now using GP2GP software to
transfer electronic health records
when patients move between GPs.
The GP2GP roll-out currently
involves practices with EMIS LV
and INPS Vision 3; other GP
system suppliers are expected to
join later in the year. Over 64,000
record transfers having taken place
to date.
CFH also says that 90 per cent
of GP practices in England are
using its Choose and Book
electronic referrals system. All NHS
hospitals are now using Choose
and Book.
In the second week of January,
the total number of patients
referred from GP surgeries into
specialist care under the Choose
and Book system broke the six
million milestone.
Wales runs trials of
electronic referrals
Trials of a new electronic system to
replace hand-delivered patient
referral letters were to start at
three Cardiff and Vale GP practices
in February, following a successful
test using dummy data. In the test,
secure transmission of the referral
between sites took on average less
than 10 seconds.
A further eight practices will
join the trial in the spring prior to
roll-out across the Cardiff and Vale
health community, which will allow
full evaluation of the service before
being made available across all of
Wales.
18-week measures made
with NHS Comparators
A release of NHS Comparators in
January means NHS organisations
in England can check their
performance against the
government’s upcoming target to
reduce the wait from GP referral to
hospital treatment time to 18 weeks.
NHS Comparators also
includes information from other
NHS organisations.
07
Professionalism makes a
difference to patient safety
Professionalism in health informatics, through actions such as
registration with UKCHIP, makes a difference to patient safety, say
Mik Horswell and Jean Roberts, UKCHIP Board members.
It is timely to reflect on personal data
handling in the light of recent events,
predominantly outside the health
informatics arena.
The risks to patients from poor
information handling have many facets
and can be reduced by actions
addressing:
The information content of the
patient records and the evidence base
on which clinicians make decisions
about interventions and progress
towards satisfactory clinical outcomes.
These must be of an appropriate quality
in terms of accuracy, completeness
and timeliness.
Accessibility and availability of
necessary data, in a useable form, when
it is needed by those authorised to see
it. Reference to pertinent data (both
operational and research) is crucial to
good decision-making at all levels.
Sensitive management of patient
files, in terms of auditable tracking of
which authorised individuals are
enabled to enquire on, add to or
otherwise modify data and compliance
with the wishes of the data subject.
Controlled sharing of data between
entities – whether people, organisations
or across sectors, especially for health
with social care.
Development of robust systems that
cover all the functions that clinicians
need in their day-to-day work, in the
use of the data for operational
management and in an anonymised
form for strategic planning.
All the points above relate to good
governance and best practice. As noted
in the recent survey conducted by the
UK Council for Health Informatics
Professions (UKCHIP), there is a view
08
in the domain that asks the question:
‘all clinicians must register with a
professional organisation before they
can practice; why should health
informaticians be any different?’ – and
in order to ensure patient safety, we
support this sentiment.
The survey findings were also
verified during workshops run by
UKCHIP on professionalism. Recognising
professional competence cannot be left
as an act of faith, so UKCHIP has in
its priority task list for 2008 to inform
employers how professionally-delivered
informatics can impact on their direct
care and management responsibilities.
The UKCHIP strategic plan moves
voluntary registration towards more
formal accreditation, though not to
mandatory requirements in the
short term.
However, in a parallel development
in a clinical area not previously
formally so recognised, members of the
Institute for Complementary Medicine
are now (from January 2008) on the
same track involving a voluntary
registration phase similar to that in
which health informatics is currently
engaged. See: www.i-cm.org.uk/
education/regulation
In addition to registering and
periodically re-validating an individual’s
fitness to practice, UKCHIP is exploring
personal accreditation, which attracts
employer recognition, and also the
management of accreditation of health
informatics services and of educational
health informatics courses from any
source.
Staff who are ‘professional’ put
public benefit above all else (Benson,
1992) and work to a code of conduct,
acting appropriately. Since 2002 the
initiative to create a profession of
health informaticians has been
developing through UKCHIP with a
growing number of registrants.
Whilst still a voluntary registration
body, UKCHIP has developed:
a full code of conduct;
a registration protocol that is used
by peer assessors to recognise an
applicant at one of three levels or as a
pre-registered registrant;
continuing professional development
criteria that facilitate registrants in
demonstrating that they are still ‘fit to
practice’;
procedures for the withdrawal of
registration from those who do not
continue to operate effectively;
an appeals procedure against the
level of registration or withdrawal
of registration.
We would strongly urge all those
who are working in health informatics,
particularly those in operational
locations which impact directly on
patient care, to consider (continuing)
their registration with UKCHIP in
order to demonstrate their commitment
to recognising their role in preserving
patient safety.
For those who perhaps would say
you work in will help you to prioritise,
for example, the call from the
paediatric special care unit or the
finance department call that came in at
an earlier time.
For those in far flung places who
write software for the health domain,
technically testing for all contingencies,
facilitating end user evaluation and
incorporating robust validation, audit
they personally have no impact on
patients, please consider the following
scenarios:
and recovery processes – whether
explicitly in the initial contract or not –
will enhance your reputation and
provide solutions that reduce risk and
increase patient safety.
If you ‘fix kit’ – think what
clinicians and health managers will find
problematic if they cannot get efficient
access to their decision support systems
and individual patient clinical histories
because your response was less than
speedy or your fix was a
temporary ‘patch’.
For business analysts who put
together routine data returns for
organisational or strategic scrutiny –
you only have to reflect on the potential
harm that might ensue if you do not
handle data sensitively and
appropriately to the prevailing legislation.
For those on help desks –
understanding the health environment
To err is human
The case studies we describe are not
scaremongering. A five-year review
based on responses to the 1999
American Institute of Medicine report
‘To Err is Human: Building a Safer
Health Care System’ (Kohn et al,
2000) emphasises that humans
are prone to error and urges
safety vigilance.
All the five areas that it states hold
great promise for patient safety have a
significant information component,
which, if not addressed appropriately,
jeopardises the achievement of better
patient safety. The areas include
improving communication, enhancing
rapid responses, preventing healthcareassociated infections and adverse
drug events.
Case studies prove the point
Drilling down to case studies used to
outline progress so far, it is also not
difficult to see, in the current
technological environment, where
informatics plays an integral role at no
more than ‘two degrees of separation’
(Watts, D, 2004).
Enhanced analytic capability
contributed to a 50 per cent reduction
in events of harm per 10,000 patient
days. Empowering frontline staff with
proven tools contributed to a 100 per
cent increase in perceived preventability
of safety events. Establishing a rapid
results team, to intervene early with
patients showing signs of medical
deterioration before they suffer acute
crises, contributed to a 15 per cent
reduction in cardiac arrest and a
3.95 per cent reduction in hospital
mortality rate. Facilitating evidencebased practices in ICU contributed to a
better than 10 per cent decrease in
lengths of stay and 18 per cent lower
mortality.
Such improvements cannot be
facilitated without adequate informatics
services delivered by professionally
competent people.
The health informatics community is
broad and the effects it can have on
reducing risk and improving patient
safety are legion. Coming together
under a recognised registration/
accreditation body clearly demonstrates
that individuals, their employers and
their suppliers recognise the significant
impact that health informatics can have
on enhancing healthcare delivery,
management, research and planning
over time.
Increasingly, since UKCHIP was
launched in 2004, endorsed by the
National Patient Safety Agency, and
since then, the case for informatics
expertise as a core component in health
services is getting stronger and its
contribution to safe patient care is
getting clearer.
Full references are available on the
website: www.bcshif.org
09
Is it safe to share a
single electronic record?
Is it desirable and safe to have a single shared electronic patient record (SSEPR), asks Mary Hawking,
a GP and level 3 UKCHIP registrant. Here, she outlines her concerns.
A great deal has been written about the
electronic health record/electronic
patient record (EHR/EPR) without any
clear agreement about what it is or
even what functions it is supposed to
serve. This can make rational
discussion difficult.
Even in systems where the EHR is
supposed to be shared between
different parts of an organisation –
such as the Veteran’s Administration in
the US – the rules for the internal
management are not clear.
In England, the declared intent of
the National Programme for IT
(NPfIT) is to have a detailed local
shared record – a single electronic
patient record for each individual
10
shared by all the local healthcare
providers involved in their care.
Definitions may change. I will refer to
this concept as the single shared
electronic patient record (SSEPR).
A number of important problems
such as security, confidentiality, access
etc. have been discussed extensively. I
have not seen discussion of the internal
management of the SSEPR itself or the
roles and responsibilities for the
maintenance of the record. Who is
allowed to enter and alter data for
items entered personally and by their
own organisations and data entered in
other organisations? There might be
errors – such as wrong or evolving
diagnoses – or items expected to be
changed, for example prescriptions and
management plans.
In short, who is the data controller
in Data Protection Act terms, and who
is responsible both for maintaining the
record and ensuring that action is taken
when required – especially if the
information comes from one
organisation, but the action needs to be
taken by another?
Most GP practices in the UK are
‘paperlite’; patient records are only held
electronically. These records are
essential for patient care and for the
financial survival of the practice,
especially since the introduction of the
Quality and Outcomes Framework
(QOF) in 2004 with the new GMS
contract. Information is extracted from
communications from other
organisations and entered into the
patient’s record.
General practice in the UK would
appear to be unique in its dependence
on read code – a coding system which
has terms for almost everything
relevant to general practice (including
diagnoses, procedures, values, claims) –
which makes the information machine
searchable, attributable and available
for audit.
The needs of community – district
nurses, health visitors etc. – and other
organisations in primary care are
different. Few of them have any
electronic records or an understanding
of read code. The consequences of
inaccurate coding are not part of their
training. EPRs – in the GP sense of the
term – are not mission critical
to others.
When looking at secondary care, it
is hard to see how the SSEPR would be
implemented.
At present, there would appear, in
many instances, to be a lack of
information sharing between
departments, let alone between
different hospitals and primary care.
While good quality information and
sharing is essential for patient care and
safety, is a SSEPR feasible? If so, how
would control of, and responsibility for,
the record be managed? For instance,
would a doctor in orthopaedics be able
to change the medication prescribed or
diagnoses entered by oncology or the GP?
I am aware of one system where the
organisation entering the data is
responsible as data controller for those
items, and only the people in that
organisation can alter them. This would
not appear to address the problems of
errors or prescriptions, especially when
the patient has been discharged by the
organisation. For instance, if someone
in community entered an erroneous
diagnosis of diabetes mellitus, and then
discharged the patient, would they be
permitted to go back and change the
erroneous diagnosis?
If not, how would it ever get
corrected? Would prescriptions remain
as repeat prescriptions forever once
started as repeat prescriptions by
community or on hospital discharge?
There is yet another problem with
the SSEPR when patients move house.
If the patient moves from an area
served by one local service provider
(LSP) to one served by a different LSP
or lives close to a national or LSP
boundary, can the SSEPR be moved or
include services in more than one
jurisdiction?
As a GP accustomed to working in
a paperless environment, I find the
prospect of a SSEPR disturbing – and
particularly so when these fairly
fundamental problems appear not to
have been adequately addressed.
Safer systems help to
guarantee patient safety
Measures taken by Connecting for Health (CFH) to ensure patient safety include building systems
according to standards and capturing data when things go wrong. Its approach is explained by
Dr. Maureen Baker CBE DM FRCGP, national clinical lead for safety, Clinical Safety Team at CFH.
The use of ICT in healthcare has
considerable potential to support
clinicians to practise more safely but
also has the potential to affect patient
care adversely if there are faults in the
system or if the implementation
is flawed.
In recognition of these potential
downfalls, in 2004 the Department of
Health (DH) in England asked the
National Patient Safety Agency
(NPSA) to conduct a high level risk
assessment of the National Programme
for IT (NPfIT) and to establish how
safety was being addressed within
the programme.
This investigation found that,
although there was a general
commitment to improve patient safety,
plans for the NPfIT had not, at that
time, formally incorporated safety
standards and methodology and that
other safety critical industries could be
said to have a more systematic
approach to safety. Following this
report, a series of workshops were held
to develop a clinical safety management
system (CSMS) for NHS CFH.
It was soon established that there
were no specific standards for safety in
healthcare IT, but a generic standard
for safety critical systems, IEC 61508,
was identified. This standard was based
on the safety case principle (i.e. that
manufacturers would develop and
present a case that their systems were
safe in use) and so CFH based their
11
CSMS on this principle, requiring three
key documents:
Hazard assessment (what could go
wrong with systems such that patients
might be harmed).
Safety case (how can risks be
mitigated).
Safety closure report (evidence that
safety case has been enacted and risks
have been addressed).
This approach was implemented by
CFH from 2005 with the aim that
systems would be as safe as design and
forethought would allow. To support
this work, CFH established a pool of
‘accredited clinicians’ who had been
trained in the principles of safety and
risk as applied to health IT. Accredited
clinicians are involved in hazard
assessments and in testing/assurance
work, and safety documentation must
be signed off by accredited clinicians.
This approach means that safety is
considered from a clinical perspective
by people who understand the context
in which the systems will be used.
Safety incident
management process
We take a proactive approach in
designing and building safe systems, but
it is a fundamental safety principle that
errors will still occur and that things
can still go wrong. It is therefore
important to have processes in place in
which problems can be swiftly identified
and safely managed. CFH has therefore
established a robust safety incident
management process with the aim of
12
capturing incidents that could
potentially harm patients, assessing
these incidents and ‘making safe’ within
24 hours. The term ‘make safe’ does not
mean that the problem has had a
permanent fix – rather it means that
the opportunity for harm has been
removed. This might be by
communicating information to clinical
staff, by approved workarounds or even
by switching off a system.
In the process of making safe, it is
important to ensure that the remedy
does not in itself introduce a greater
risk than the problem being addressed.
Operating this process involves having
clinical and technical staff on-call 24/7
and we are now building up valuable
information about the sort of things
that can go wrong in health
IT systems.
Innovative approaches to
clinical risk reduction
Another aspect of our work is the use
of innovations in technology to address
known patient safety problems. In
particular, we have programmes of
work in the following areas:
Right patient, right care – this
relates to technology solutions that
assist staff to properly identify patients
and to correctly match patients with
aspects of care, such as receiving the
drugs, investigation results and
procedures that relate to the
appropriate patient. We are exploring
the use of tracking technologies such as
bar coding, radio frequency
identification (RFID) and biometrics;
and also producing guidance on
wristband datasets and the use of
unique patient identification numbers
(NHS number).
Safer prescribing – work in this area
relates to developing criteria for alerts
and prompts in prescribing decision
support and in developing strategies for
dealing with medication errors, such as
use of tallman lettering in system
pick-lists.
Safer handover – interfaces of care
(eg shift handovers or being discharged
from hospital to home) are dangerous
places to be for patients. We are
exploring ways in which technology can
support provision of essential
information that will enable safe care
of patients following handovers.
Common user interface (CUI) –
even if clinical IT systems follow our
established safety processes, they are
likely to differ in the ways that they
implement key functionality. These
differences may at best cause confusion
and delay as healthcare professionals
trained on one system struggle to use
another, and at worst create risks to
patient safety. The CUI programme
addresses this problem by providing
guidance and standards to IT system
suppliers, with the aim of making the
user interfaces of clinical IT systems
used in the NHS more consistent. The
idea is that, in the long term, this will
provide our workforce with a degree of
familiarity with their electronic patient
record software, sufficient for the safe
and effective delivery of care, without
extensive re-training.
The CUI programme is driven
primarily by patient safety
considerations and follows all of the
CFH safety management practices
outlined above. It adopts private-sector
best practice in that it is led by
experienced usability professionals and
uses an iterative ‘research-designprototype-test-refine’ process. To date it
has conducted over 300 one-on-one
usability testing sessions and many
hours of contextual observation in NHS
care settings.
By collaborating with other
programmes, in particular those
mentioned above, the resulting
guidance and standards include
lessons from previous patient safety
incidents, as well as best practice from
existing UK and international IT
system implementations.
Swindells to headline at
HC08 on future strategy
The future strategy for information within the NHS will be the theme of the keynote speech by
Matthew Swindells, CIO for health, at this year’s Healthcare Computing Conference, which is
celebrating its 25th anniversary.
Sixty years ago the NHS was created
to ensure equal access to healthcare
across the UK. In the year of its
historic anniversary, the focus of the
government has shifted from providing
healthcare to the masses, to improving
the clinical experience of the individual.
This year, the 25th anniversary of the
HC conference, as ever committed to
exploring how cutting-edge technology
can be used to best deliver care, picks
out this theme over the three day event,
from 21-23 April.
This year’s event comprises 10 mini
conferences, with delegates being able
to take in a whole conference stream,
or mix and match sessions according to
their interest. The opening session will
feature Matthew Swindells, acting chief
information officer (CIO) for health,
Department of Health and Rachel
Burnett, BCS President. Matthew will
give a keynote presentation on the
future strategy for information within
the NHS, and, in particular, its role in
supporting and catalysing the changes
that will be described in Lord Darzi’s
‘Next Stage Review’.
‘Information saves lives, Matthew
says. ‘Information professionals need to
step forward and play their part in
creating an NHS that is founded on
quality, evidence and empowerment.’
Barriers crumble
Professor Stephen Kay, chairman of the
HC 2008 Programme Committee, says:
‘The traditional barriers between
organisations, professions and
individual practitioners are already
beginning to crumble, and new working
partnerships are in the making, focused
on making a better joined-up service for
each patient/client. As a result, it is
now imperative that everyone in these
new multidisciplinary teams understands
the information needs of their colleagues
more fully and uses the tools that ICTs
offer to deliver them – information is
the lifeblood of an integrated service.’
Day one of the conference will focus
on implementing national programmes,
understanding current priorities and
future challenges, making innovative
technologies work and building
capability in people and services. This
will involve sessions on how to realise
the benefits of the English National
Programme for IT, a panel discussion
on clinical software designed for
patient safety, tutorials and a number
of presentations and workshops.
Meanwhile, presentations and papers
will include the use of support workers
in an internet chatroom for people
suffering from depression, and
measuring the impact of computers on
consultations.
National programmes
The second day will also further
explore the implementation of national
programmes – including the perspective
of Wales, Scotland and the USA – as
well as supporting access, disability and
diversity and understanding healthcare.
Sessions will include the role of open
source systems in healthcare
applications, how to encourage clinical
staff to also become health informatics
leaders and whether delivering
effective, coordinated, healthcare across
the social divide is in fact a realistic
aspiration. The BCS Health
Informatics (London & South East)
Specialist Group will also host a debate
on whether the benefits of allowing
NHS organisations to choose their own
sensible and standards-complaint ICT
solutions outweighs the risks.
Day three concentrates on delivery
of care across sectors, managing risk
and supporting research. In particular,
it examines the role of general practice
in delivering clinical care. Dr Glyn
Hayes, past chair of the BCS Health
Informatics Forum (BCSHIF) describes
the relationship between GP surgeries
and hospitals and how hospitals work,
while a number of papers presented will
focus on privacy.
The conference sessions, organised
by BCSHIF, will, as usual, be
accompanied by an exhibition, run by the
British Journal of Healthcare Computing
& Information Management.
Sheila Bullas, chair of the HC
executive committee, concludes:
‘Twenty-five years after the first
conference, HC 2008 proves that
technology in a healthcare context
remains an essential enabler of service
improvements.’
Information on the conference is
correct at time of going to print.
More information
Conference: www.health-informatics.org
Exhibition: www.healthcarecomputing.co.uk
13
Virtual radiotherapy cuts
down training pressure
The development of a virtual training environment for
radiographers scooped The BT Flagship Award for Innovation at
this year’s BCS Industry Awards. University of Hull and Hull & East
Yorkshire Hospitals NHS Trust worked together on the project,
which earned them the gong, which recognises an innovative
application of technology to overcome a challenge.
Despite the role that radiotherapy plays
in modern medicine, current training
programmes all too often take place in
clinical rooms under time constraints.
Pressure is set to increase training
as the use of radiotherapy is expected
to rise by 91 per cent by 2016,
according to a report in May 2007 by
the National Radiotherapy Advisory
Group to the government. The report
‘Radiotherapy: developing a world class
service for England’ highlighted that
the UK radiology sector faces a
significant training challenge because of
the environment and time constraints.
In order to improve the provision of
radiotherapy in England, the University
of Hull, in conjunction with the
Princess Royal Hospital, developed the
Virtual Environment Radiotherapy
Training system (VERT). It aims to
increase clinical training capacity for
radiographers while reducing the
14
pressure of training on service
departments. VERT, which is written in
C++ and using OpenGI, does this by
providing a virtual training environment
that mimics a real-life situation,
providing learning and training for
students in a ‘safe’ environment.
During 2007, VERT was introduced
to three training sites in Birmingham,
Belfast and Aarhus (Denmark). This is
the first time that training in an
immersive 3D virtual environment has
been adopted by clinical training
centres in radiotherapy. VERT recreates
the radiotherapy machine (known as
Linac), the room in which it is situated
and the patient lying on the couch.
Lifelike replication
Actual Linac control devices have been
integrated into VERT which means that
users can control the virtual reality
Linac exactly as they would in reality.
The accurate, lifelike replication of a
radiographer’s working environment
reinforces the learning experience and
makes VERT a viable alternative to the
real thing.
VERT extends students’
understanding of radiotherapy from
accurately setting up patients to the
irradiation of tumours. VERT can be
used in two modes. ‘Demonstrator
mode’ allows for classroom style
teaching, while ‘hands-on/flight
simulator mode’ enables a trainee to
simulate radiotherapy treatments and
practice set-up procedures.
The virtual environment comprises
many elements including a stereo 3D
projection system, 3D glasses, a
head-tracking system, projection
screen, a hand-pendant and interface
electronics and a PC with 3D stereo
enabled graphics card.
Training on actual Linacs is
exceptionally expensive, so VERT
reduces training costs. Also, Linacs are
continually in use, which can limit
access for training. VERT enables more
extensive training and better
understanding among trainees which
ultimately should improve cancer
patient care.
Patients will also benefit from
decreased waiting lists as VERT
reduces the training demand on
treatment rooms.
‘The role that radiotherapy plays in
helping patients beat cancer is
undeniable,’ said Paul Excell, chief of
operations, BT Group Chief Technology
Office. ‘All stakeholders impacted by
VERT stand to benefit and the system
is a worthy winner as it encapsulates
everything that this award stands for.’
The latter half of 2007 has seen the
implementation of a national roll-out
programme for VERT in response to
the National Radiotherapy Advisory
Group, which recommended the
creation of 10 educational facilities and
offering the system to all radiotherapy
departments in England.
Putting eHealth into
context in Africa
If the UK is to transfer eHealth innovations successfully to Africa, it needs to pay more attention to
contextual and organisational issues, says Dr Adesina Iluyemi, PhD researcher, University of
Portsmouth. In this article, he looks at what to consider in developing effective eHealth in developing
countries, based on his presentation at MedInfo2007.
Many of the delays in the Connecting
for Health (CFH) programme have
been attributed to too much focus on
technology with little importance
attached to contextual social and
organisational issues. These include lack
of clinical engagement and consideration
of NHS organisational culture in the
implementation process. This is despite
the fact that the lack of recognition of
these factors has been blamed for high
failure rates in IT implementations in
developed countries like the UK,
especially in the health sphere.
As the UK government plans to
employ eHealth to improve healthcare
in developing countries, it needs to
recognise and understand the
importance of these factors in
successful north-south eHealth transfer.
CFH, together with the WHO, plans to
share some of its eHealth innovations
with developing countries under the
emerging ‘Sharing eHealth Intellectual
Property for Development’ (SHIPD).
It is imperative that this IT failure
culture should not be shared as part of
the transfer process. The financial
burden of IT failures is not a luxury
that the fragile economies of these
countries can sustain.
Research evidence (for example that
by Musa, Mbarika, & Meso, 2005)
suggests that north-south technology
transfer is a complex and contentious
issue with numerous recorded
sustainability failures, and the need to
understand contextual issues deemed
important for success. The following
example of a recent eHealth transfer
from the UK to Africa illustrates
contextual social and organisational
issues in eHealth technology transfer.
The Mobile Map of Medicine is an
eHealth innovation developed by a
private company but fully endorsed by
the NHS in what can be termed as a
Public Private Partnership (PPP)
initiative. This was introduced to a
hospital in Kenya to assist health
workers in accessing diagnostic and
therapeutic information for patient
management through wirelessly
connected mobile, portable and fixed
computers.
This project was well received and
anecdotal evidence indicates that this
eHealth tool has impacted on health
workers’ capacity building. Knowledge
acquisitions with improvements in
patients’ care pathway management
were attained. However, this success
may be short-lived as the porting of the
eHealth software to mobile computers
might soon be discontinued due to the
lack of financial incentive for the
private developer.
‘The financial burden of
IT failures is not a luxury
that the fragile
economies of these
countries can sustain.’
If discontinued, the long-term
sustainability of this clinically beneficial
tool might be in jeopardy, as mobile
computers are better suited to the
resources and energy poor environment
of most developing countries. The
lessons that can be learned from this
scenario are that:
The PPP model from the UK might
not be replicated successfully in Africa
because private organisations are in
business to make money. Successful
eHealth development in Africa might be
better achieved through a social
enterprise model. This model has been
adopted successfully in the development
and implementation of a mobile
eHealth tool known as ‘Jiva TeleDoc’ in
India (www.jiva.com/teledoc/).
The limited financial resources and
erratic electrical power have a role in
the choice of appropriate eHealth
technology. The use of low-cost mobile
computers powered by locally
fabricated solar panels for eHealth
purposes have been demonstrated in
Uganda for the past three years.
Mobile technologies
Hence, it may be a sustainable strategic
practice to learn from existing
successful eHealth models in some
developing countries.
For example, mobile technologies
have demonstrated considerable impact
on health workers’ capacity building
and health system performance
improvement in the UHIN programme
in Uganda.
Recognising and paying attention to
contextual human and organisational
sustainable IT transfer and
implementation factors should be a
matter of paramount interest to
international development policy
makers in the UK. Mobile technologies
should also be considered.
Ongoing research work at the
Centre for Healthcare Modelling and
Informatics, University of Portsmouth
is aimed at unravelling these
mobile/wireless eHealth success factors
within Africa’s health system.
References are available at:
www.bcshif.org
15
Meet the group
BCSHIF Strategic Panel
The BCS Health Informatics Forum constituency is led by its Strategic Panel – a group of experts,
individually recognised as thought leaders and influential opinion formers.
Chair: Prof Graham Wright FBCS CITP
Graham is director of the Centre for
Health Informatics Research and
Development. He is the programme
director for the MSc Health Informatics
at the University of Winchester. He is a
co-founder of the Open Software Library
and UK representative to the
International Medical Informatics
Association (IMIA) and chairs its open source working
group. Graham is a GP educator with the Severn Institute
based in the Office of General Practice in the Great Western
Hospital, Swindon.
Immediate past chair: Dr Glyn Hayes MBChB
DRCOG FBCS CITP
Glyn is a medical practitioner who
designed one of the first consulting
room GP computer systems. A founder
member of the Primary Health Care SG,
he is now its president. He is also
president of the UK Council for Health
Informatics Professionals, the
registration body for health
informaticians. Glyn has also represented the UK on the
IMIA and was the chair of its primary care working group.
Vice chair: Ian Herbert MBCS CITP MCIWEM
Until recently Ian was a senior
consultant working for the NHS on the
National Programme for IT (NpfIT),
and is now an independent health
informatics consultant. He led the team
that produced the Update Primary Care
System and his work includes GP
systems’ requirements for accreditation.
He is an active member of the Primary Health Care SG,
sits on BCS Specialist Groups Executive Committee, is a
member of BCS Council and the BCS Trustworthy
eGovernment Group.
Webmaster: Dr John Newell CEng MBCS CITP
A former physicist in medicine, John edited a respected health
informatics journal for many years. Now retired, he oversees
the websites of BCSHIF.
16
Secretary and HC executive chair: Sheila Bullas
MBCS CITP
Sheila is a strategist with a background
in medical laboratory technology,
informatics and organisational change.
She is founder and director of iBECK,
an independent consultancy. She is
particularly interested in large, complex
and innovative programmes. Sheila is
currently leading transformation
programmes. She is a member of BCS Council and leads the
Health Informatics Now editorial board.
Policy group lead: Dr Jean Roberts CEng FBCS
CITP MHM
Jean is a health informatician with
extensive experience in strategic health
initiatives, knowledge exchange, project
input in informatics and business areas
and marketing, communications and
promotion. Key assignments to date have
involved her in health informatics strategy, procurement, application solutions
and training. Her many activities include lecturing at
University of Central Lancashire.
European Federation for Medical Informatics
(EFMI) rep: Dr Helen Betts MBCS
Helen trained as a midwife and is
currently the dean of Faculty of Social
Sciences, University of Winchester. She
has been a member of the HI Nursing
SG (NSG) since the late 1980s and has
served on the executive and as an
assistant editor for NSG Journal, ITIN.
She has published on health informatics
since 1988 and attended many major conferences.
International Medical Informatics Association vice
president: Dr Peter Murray PhD RGN FBCS CITP
Peter is IMIA vice president for working groups and special
interest groups; currently he also has responsibility for
strategic planning implementation. His main informatics
interests are in e-learning and open source software. He has
been active in BCS HI Nursing SG, serving as chair and
journal editor and as representative to IMIA-NI. He writes
many blogs, including for the BCS website: ww.bcs.org/blogs.
His online biopic is at www.peter-murray.net
Professional development board chair:
Andrew Haw BSc MBCS
Andrew is chief information officer of
Circle, an independent sector healthcare
provider. Prior to this, he was director of
information & communications
technology & EPR, University Hospital
Birmingham (UHB) NHS Foundation
Trust from 2000 to September 2007,
latterly seconded to Connecting for
Health. He has spent the last 30 years working in informatics
and IT. Andrew was chair of ASSIST from 2004 to 2007.
Primary Health Care SG chair: Ian Shepherd
MRPharmS MBCS CITP
Ian is a pharmacist and has worked
within hospital pharmacy, community
pharmacy and latterly for the Royal
Pharmaceutical Society of GB,
developing and implementing the
professional information management
strategy for pharmacy. He has worked
on the development and implementation
of both large and small scale information systems within both
private and public sector organisations.
Interactive Care SG chair: Mark Outhwaite BSc
MBA MIHM MBCS
Mark is an independent consultant
specialising in strategic consulting in the
public and private healthcare sectors. His
background spans 13 years in NHS chief
executive roles and director of technology
adoption at the NHS Modernisation
Agency. He is now director of a community
interest company formed to develop new
ways of using internet technology to combine social networks,
personal health and lifestyle data and intelligent analytics to
promote ill-health prevention and self-care.
ASSIST chair Brian Derry Cstat FBCS CITP
Brian began his career as a government
statistician, ultimately joining the
Department of Health in Leeds in 1992.
There followed spells on secondment to
Leeds Health Authority and Leeds
Teaching Hospitals NHS Trust (LTHT),
where he was appointed director of
informatics in 2005. Brian is a member
of the Government IT Health Sector Informatics Steering
Group and the board of the NHS Faculty of Health Informatics.
Nursing SG chair: Richard Hayward MBCS
Richard is a senior lecturer in nursing
and applied clinical studies at
Canterbury Christchurch University with
specific responsibility for management
and health informatics teaching. He is a
member of the Management
Qualifications Working Group at the
BCS and has been involved in the BCS’s
Professionalism in IT Programme.
HC programme chair: Prof Stephen Kay CEng
MBCS CITP
Steve is professor of health informatics
at the University of Salford and associate
head (research) in the School of Health
Care Professions. He is also chair of the
programme committee which organises
the programme and content of the annual
Healthcare Computing Conference.
Northern SG chair: Dr Tom Sharpe CEng MBCS
CITP ARCS
Tom was a lecturer in health informatics
until his retirement in 2007. He is now a
member of the BCS Health Informatics
Degree Working Group, which is drawing
up guidelines for the accreditation of
health informatics courses. He has been
chair of the HI Northern SG since 2004,
leadin the group in organising talks.
Scotland SG chair: Dr Charles Docherty MBCS
Charles is a senior lecturer in practicebased learning at Glasgow Caledonian
University. He represents his university
on the IMIA, is on the BCS nursing
specialist group, Connecting for Health’s
national advisory group, and is an
organising committee member of the
Association of Common European
Nursing Diagnoses, Interventions and Outcomes. He
represents BCS HIS on the National eHealth nursing,
midwifery & allied health professions (NMAHP) clinical leads
group in Scotland.
London & South East SG chair: Barrie Winnard
FBCS CITP
Barrie has been ICT head at Moorfields
Eye Hospital since 1997, having moved
there as information manager in 1994.
He has been in the NHS for 35 years,
20 of which as a radiographer at
Chesterfield Royal Hospital. He moved
across to information during the resource
management era in the early 1990s.
Having become IT manager of Chesterfield Royal Hospital in
1992, he has spent the last 15 years in information and IT.
17
Clinical document sharing
supported by standards
Obtaining electronic clinical interoperability is the goal of Integrating the Healthcare Enterprise (IHE)
UK. Its steering committee is to become a BCSHIF group. The importance of the topic, and IHE’s work
on sharing documents, were explained at the last BCSHIF seminar.
Semantic interoperability is important
in healthcare for a host of reasons, said
Ian Herbert, vice chair of BCS Health
Informatics Forum (BCSHIF).
Healthcare is becoming increasingly
cooperative and patients more mobile,
so information needs to follow the
patient and mean the same thing to all
those involved in his or her care.
Suppliers do not want to keep
re-designing specific system-to-system
interactions, and buyers wish to avoid
supplier ‘lock-in’.
‘This need for semantic interoperability is behind the current push
towards standards development by
various bodies,’ said Ian. ‘Standards
should cover physical interconnection,
application interconnection and the
representation of patient data
and knowledge.’
Some standards are being developed
internationally, such as the SNOMED
CT terminology, HL7 message designs
and the International Standards
Organisation (ISO) standards for
electronic patient records. But there
are also regional bodies at work in the
area, such as CEN in Europe, as well as
national units, such as ANSI (USA),
DIN (Germany) and BSI (UK).
The result, according to Ian, is a
plethora of standards, which do not
share an underpinning semantic model.
Some standards overlap, others are
rivals and there are elements of
semantic conflict between some of
them. There are also gaps – for instance
work is only just starting on the
interface between sensors you can wear
and use at home and systems at large.
And many standards are difficult to
interpret, and so to use consistently.
‘We therefore need to profile
standards to remove scope overlaps,’ he
said. ‘We need to agree an underpinning
18
model, and we need to plug gaps
in standards.
‘This needs to be done across
standards bodies, and CEN, ISO and
others are working increasingly closely
together. We also need to demonstrate
that current standards can work, for
example, by actually developing
interoperable systems based on them.’
Nick Brown, chairman of IHE-UK
steering committee, continued the
XDS means that data
can stay at source.
As there will always be
local documents that
are not on the Spine,
being able to search for
them would be a
valuable facility.
session by explaining that the
methodology of the IHE, an
international not-for-profit
organisation, enabled healthcare IT
systems users and suppliers to work
together to obtain interoperability. IHE
tailors existing standards to fit
requirements for specific clinical tasks
by creating profiles of them.
‘It’s about selecting parts of
standards, not re-writing them,’
expanded Nick. ‘The IHE technical
framework documents specify
significant clinical tasks where
interoperability has been found to be
problematic and profiles of existing
standards support them to
achieve interoperability.’
He explained that annual test
sessions were organised by IHE in
various parts of the world which
enabled suppliers to submit their
software applications for testing and to
show that they could interoperate
successfully with the software
applications of three other suppliers.
Suppliers then included details of
which IHE integration profiles were
supported by each of their products.
The results are published on the IHE
website and this enables purchasers to
buy systems from different suppliers
that conform to appropriate IHE
specifications and so will work
properly together.
IHE is currently developing
integration profiles for the easy sharing
of clinical documents. The scheme could
be used within a health community
and/or within an organisation such as a
hospital trust.
When a clinician wishes to share a
document with others a copy is stored
in such a way that authorised
colleagues can access it. The document
and its associated descriptive
information (metadata) are sent to a
document repository. The repository
application stores the document and
sends the metadata and the document’s
location to a centralised registry so
that colleagues can easily search for it.
The basic descriptive information can
be automatically provided by the
computer system. This makes the
submission of documents for storing
very easy.
The XDS processs
The cross enterprise document sharing
(XDS) process starts when a patient
visits a care provider and a document is
produced that needs to be shared. The
enterprise submits the document (e.g.
as a pdf file) with its metadata to
either a local or centralised document
repository. The metadata also goes into
an ebXML document registry.
Metadata typically includes the
name and category of the organisation
generating the document, when it was
published, the document type, the start
and end time of the event being
described and so on.
A clinician wishing to access data
can use an application which searches
the registry and displays a list of
documents found. He or she can select
one or more items from the list and the
application will then retrieve and
display them. This is simple to use and
can work for existing documents as well
as new ones.
A more complex use involves
documents that include coded
information. The HL7 clinical document
architecture (CDA) format supports
both free text and coded information,
explained Nick. Graphs could be
generated from data found within a set
of retrieved documents, for example.
‘Documents can be submitted as a
set or can be added to a folder,’ said
Nick. The issue of the need for folders
caused some debate among the
audience, some of whom saw it as
unnecessary as a search would find
items whether or not they were
included in a folder.
Nick explained that the important
property of an IHE XDS folder was
that documents could be added to it by
different people over a period of time.
It provided a convenient way to fulfil
the requirement to group documents
expressed by some users. The facility
did not need to be used by those who
did not want it.
An audience member suggested that
a potential use of XDS could be to
provide communication of records
between the National Programme for
IT (NPfIT) local service provider
(LSP) clusters. Another point made by
a delegate was that XDS means that
data can stay at source. And, as there
will always be local documents that are
not on the Spine, being able to search
for them would be a valuable facility.
The audience also voiced strong
opinions on the importance of IHE
work being aligned with NPfIT and
Connecting for Health (CFH). It would
be useful if an application could be
produced that could search for and
retrieve local documents as well as
those available via the NHS Spine.
Nick emphasised that IHE would be
delighted if Connecting for Health got
involved and that there should not be a
problem adapting the profile to fit. He
believed that there was interest in IHE
and XDS in some quarters within
NPfIT, but no practical work was
progressing as yet. He suspected that
CFH may well have got involved, if IHE
had been working on XDS and attached
to BCS when NPfIT was formed.
‘The scheme has been implemented
by a large number of different suppliers
and the fact that it can be used to share
existing documents as well as newly
created ones was important,’ he said.
There is significant interest in the
UK in this specification and an
important meeting is being jointly
organised by IHE-UK and BCSHIF on
9 April in Oxford. The programme
includes a visit to the IHE
Connectathon which is being held at the
same venue. Details are at:
www.bcshif.org
Further information
www.ihe.net
www.ihe-europe-org
www.ihe-uk.org
19
The NHS23 still favour
an independent review
The concerns of the NHS23, the academics who wrote an open letter calling for an independent review
of NPfIT, are not yet allayed. Tony Solomonides, one of the 23, spoke at the BCSHIF meeting on 22
January. Helen Boddy reports.
When the National Programme for IT
(NPfIT) was first announced Tony
Solomonides said he had a sense of
relief. He had been working on a survey
of independent databases for
Information for Health – and the Local
Implementation Strategy Committee –
which was just not adding up. They had
found 300 different databases existed,
30 were useful but they thought they
could only pay for three.
‘The NPfIT announcement made me
think “phew! – the problem is being
taken out of my hands,”’ he said. ‘The
NHS23 have been painted as antiNPfIT, but we are not; we’re highly
committed to sound healthcare
information systems. We would still be
in favour of the main goals of the
programme, and we recognise that
some things have changed, but there is
still a need for a review.’
Nevertheless, by April 2006, Tony
argued that both public and private
signs showed that things were going
wrong with NPfIT, and the 23 academics
signed an open letter to the House of
Commons health select committee to
call for an independent review.
Several among the 23 have been
very active, stressed Tony, and they were
from different disciplines – computer
science, software engineering, and
information systems. Tony identified
himself with both computer science and
information systems. He started out in
clinical informatics and moved into
health informatics in 1998.
Concerns reinforced
Following their letter, five to six of the
NHS23 were invited to talk to Richard
Granger, the then head of Connecting
for Health (CFH). Although Tony was
20
not among the group, what he heard
about the meeting reinforced the
concerns in their letter. The most
worrying point for him was that there
was a ‘double blind’ architectural
approach attributed to commercial
confidentiality.
The concerns of the NHS23 have
continued. One worrying sign was that
individuals who expressed doubts or
objections, and in particular one local
service provider employee who
developed a peer critique of NPfIT,
were disowned and silenced.
‘There was a feeling that anyone
who stepped out of line would be
silenced,’ said Tony.
Although NPfIT is now moving to
local implementation, as announced
late last year, Tony thinks it is too little
too late. ‘The lid was on hard, and has
now been taken off a bit,’ he said. Local
teams have responsibility but they have
little choice. What if they don’t know
where to turn? Will they just do
nothing?’
Ongoing comment
Some of the NHS23 continue to be
active in commenting and making
critiques on NPfIT. In a recent
discussion on BBC TV’s Newsnight
about government data loss, Ross
Anderson talked about how the lessons
learned should be applied to the
development of electronic health records.
‘There are particular concerns
about role-based access controls,’ said
Tony. ‘CFH’s own analysis shows there
are 40 million possible combinations of
access controls. Therefore there will
need to be a compromise, and some
data will be put at risk.’
Martyn Thomas – in his evidence to
the Healthcare Select Committee –
offered examples from DERA’s review
management, unintended and
counter-intuitive consequences. These
have mainly been by Colin Tully, Frank
Land and Mike Smith and to some
extent Ray Ison, James Backhouse and
Tony Solomonides.
Colin Tully was remembered as
saying: ‘How can observing yourself and
your problems, and seeing what works,
and what doesn’t, be bad?’
Ongoing actions include Tony
supervising a student, Mark Olive, at
the University of West England, who is
studying evidence from practice. He is
looking at integrated care pathways
and variance, knowledge management
versus control of the clinician, which is
seen by some as the Taylorisation
of medicine.
in strategy.
Tony was asked what he thought
could now be done, given that the
programme is in full swing. He
suggested that Martyn Thomas could
advise the government on how to
conduct a review that would not stop
the programme while underway.
Examples could be drawn from the
MoD.
A review could also clear up how
the local process should work.
An audience member from CFH
countered that implementation is now
calming down and working better
locally.
A website containing over 350
pages of critical comment on NPfIT
can be found at: www.nhs-it.info
‘There are particular
A tribute to
Colin Tully
concerns about role-based
access controls. CFH’s
own analysis shows there
are 40 million possible
combinations of access
controls. Therefore there
will need to be a
compromise, and some
data will be put at risk.’
of the Swanwick En-Route Air Traffic
Centre’s software. This was conducted
while the centre remained in operation,
and, Tony, suggested, could help in
devising a review for NPfIT.
Closely related to Martyn’s critique
is that of Brian Randell, based on the
issues of centralisation, evolutionary
acquisition, socio-technical systems, and
constructive reviews. These themes
were developed in a different talk to the
BCS Socio-Technical Systems
Specialist Group on 7 February 2008.
Other critiques have come from the
information systems point of view –
stressing organisational issues, change
Meanwhile, Harold Thimbleby has
developed a twin track critique, on the
one hand of the usability of the systems
and the other in conjunction with the
Welsh programme.
Still critical
In summary, Tony said that the NHS23
remain critical of:
relations with stakeholders, poor
requirements process;
the architectural approach,
especially:
dependability/fault tolerance;
security;
centralised storage.
slow, late and unreflecting change
EurIng Professor Colin Tully MA
(Cantab) FBCS CITP CEng, a
leading light in the NHS23, passed
away on 27 December at the age
of 71.
Tony Solomonides began his
presentation at the meeting with a
tribute to Colin, whom he
particularly remembered for his
astute questioning in his role of
external examiner and more
recently for his incisive analysis of
the National Programme for IT.
The BCS Health Informatics
Forum (BCSHIF) added its
condolences. Colin had a long
association with BCS and the
forum. He played an active part in
Healthcare Computing conferences
and the Primary Health Care
Specialist Group.
Colin will probably be best
remembered for his research into
the domains of software engineering
and information systems, including
software processes, capability
maturity models, software life
cycles and method and tool
integration.
He retired from the post of
associate dean at Middlesex last
year, but was still very much part of
the academic community.
21
Pilot assesses whether
services are effective
The Connecting for Health Capacity and Capability Programme has been piloting a benchmarking and
accreditation scheme for health informatics services. Progress to date was described at the BCS Health
Informatics Forum seminar on 22 January.
‘Discussions have been going on for a
long time about assessing and
developing the effectiveness of
informatics services and teams in the
NHS,’ said Di Millen, head of
informatics, Connecting for Health
(CFH) Capability & Capacity
Programme.
The project builds on work initiated
by the NHS Information Authority in
2003 and an ASSIST paper presented
to CFH in early 2007, as well as work
planned in the South East Coast
strategic health authority (SHA) area.
22
This health informatics service
benchmarking and accreditation project
comes under health informatics
development, which is one of five areas
covered by the Capability & Capacity
Programme:
enhancing executive leadership;
programme and project
management;
organisational readiness assurance;
deployment risk mitigation;
health informatics development.
Tribal Group has worked with the
programme to develop a tool and model
to benchmark and accredit health
informatics services via a set of
measures and metrics. The
benchmarking model covers strategic
(governance, planning, customer
relationship) and tactical issues
(resources, business process,
organisation), as well as what people
do operationally.
‘From the tool, providers of health
informatic services can see where they
are performing well and where there is
room for improvement,’ said Mike
Sinclair, national project manager.
The first phase of the pilot exercise
trialling the tool was completed in
November last year in three areas:
South East Coast SHA, Barts and the
London NHS Trust, and THIS (a north
of England health informatics service
hosted by Calderdale and Huddersfield
NHS Trust). Both service users and
suppliers took part in the pilot.
The pilot indicated a number of
areas where further work needs to be
undertaken, including the need:
to refine the tool and model further;
to integrate it with existing NHS
service and ICT based initiatives;
to develop a benchmarking club,
and establish a central review body to
run an accreditation scheme on a
national basis.
These, and other initiatives (such as
the development of a resource library
making examples of best practice
widely available, and the development
of the tool in the web environment), are
being taken further forward in a second
phase pilot.
‘We are currently identifying a body
to run a formal scheme in the future,’
said Mike. ‘The tool is so complex and
multi-layered that we also need to
make this easier to access, so we are
looking at making it web-based. Of
fundamental importance is the need to
integrate any future information and
performance management scheme with
other measures used in the NHS, so
that when you are completing the
assessment, you are not duplicating
input and/or effort. We are doing what
we can to ensure this.
Six sites have expressed interest in
being involved in the pilot, which should
be completed by April 2008.
Following the pilot, the team is
planning a phased approach to
introduce a formal accreditation
scheme nationwide. This would probably
start on a ‘club’ basis, evolving towards
the voluntary introduction of an
accreditation scheme for early
adopters, and finally move to a formal,
nation-wide scheme.
More information will be made
available through websites and
national workshops over the next two to
three months.
Further information
www.connectingforhealth.nhs.uk/
systemsandservices/capability
ASSIST
Events receive boost from
coordinator and commerce
Several of ASSIST’s current activities aim to strengthen its presence as a professional body, explained
Simon Anderson, vice chair of ASSIST and technical architect in Staffordshire at the BCS Health
Informatics Forum seminar on 22 January. Helen Boddy reports.
The diverse number of activities with
which ASSIST is involved currently
range from organising branch meetings
and a conference to input into health
service reviews.
‘We are trying to take good practice
from certain ASSIST branches, such as
the north-west branch, and implement
it in other areas,’ said Simon. ‘The aim
is to have a wide range of regular
events at appropriate times, and to
attract a more diverse range of people
in the audience.’
ASSIST is also aiming to make sure
that its events are promoted to a wider
BCS audience via its internal channels.
The ASSIST committee has
appointed a national events
coordinator. By creating this post,
ASSIST aims to run more regular,
bigger events with 40-50 people
attending wherever possible.
The main ASSIST event of the year,
the annual conference, is currently
being planned for May, to be held
in London.
‘We think it’s time to move it after
two years in the north-west and
previous events in the West Midlands,’
said Simon.
‘Moving around the country will
help ASSIST members of all levels to
participate. There will be one keynote
speaker, the focus will be on sharing
good practice and success, and the aim
is to have strong audience participation.’
ASSIST events are set to gain from
the signing of a memorandum of
understanding (MOU) with Tribal
Group and BT. By improving links and
working with the private sector,
ASSIST hopes to benefit from its
partners’ resources, such as speakers,
technology and accommodation. In
return, the partners can obtain direct
intelligence from the NHS on strategic
and other issues, and access to a wide
range of knowledge both within the
NHS and outside. Simon stressed that
it is not a commercial contract and
great care is being taken within the
contracts with them.
Unrelated to the MOU, ASSIST has
another indirect link with Tribal Group.
Both organisations have been involved
in Connecting for Health’s Capacity &
Capability Programme. Tribal Group
developed a health informatics services
benchmarking and assessment tool (see
p22) while ASSIST has helped arrange
events promoting it and has worked
with Connecting for Health in
delivering sessions
ASSIST has been involved in
several workshops to date for the
Swindells Review (a major review into
health informatics service provision)
team. Some of its members have also
been interviewed by Richard Jeavons,
director of the Service Implementation
Team at Connecting for Health, and
others. ASSIST was invited to
nominate members for the project
boards. ‘However,’ said Simon,
‘ASSIST’s role remains one of
constructive critical friend.’
23
NORTHERN SPECIALIST GROUP
Access by patients helps
avoid another Shipman
Making the contents of patients’ records visible to patients offers benefits but creates challenges,
according to Dr Amir Hannan, a GP in Hyde, who has already done so. This article, by Northern Group
chair Tom Sharpe, is based on Amir’s talk and live demonstration to the Health Informatics (Northern)
Specialist Group in December 2007.
A patient’s medical record performs a
vital role in his or her ongoing care.
Patients cannot feel confident that they
will be safely treated unless they are
confident that the information in their
record is correct.
An extreme example of this can be
seen in the case of Harold Shipman, a
GP who caused death to patients by
overdosing them with opiates and later
falsified the records to cover his tracks.
If the contents of the patients’ records
had been visible to patients or their
carers, the chances of this going
undetected would have been minimal.
Dr Hannan took over the very same
practice in Hyde, on the outskirts of
Manchester, where Shipman previously
worked. In order to restore the
confidence of patients in their doctor,
he took the bold step of offering them
complete access to their own medical
record.
This was done electronically, first by
means of a CD, and later online. He
soon found that, although there were
undoubtedly some challenges to face, he
was definitely on to something, and the
service was greeted with tremendous
enthusiasm by the patients who signed
up for it.
The project is a collaboration
between the GP systems company
EMIS, another company called PAERS
(Patients Accessing Electronic
Records), GPs and patients, many of
whom have been actively involved. The
solution is generic and although it was
demonstrated with an EMIS system, it
could work with any other GP system.
24
Access is currently passwordprotected, but there are plans for
2-factor authentication in the near
future. The patient normally controls
access: if a patient wishes, he or she
can give access to relatives, carers etc.
simply by giving them their password.
However, for the protection of patients
and particularly children or those
whose competence is challenged, a
comprehensive set of guidelines is
in place.
Bookings to suit
The most basic facilities of the system
are direct appointment booking and
repeat prescriptions. In contrast to
conventional telephone booking, the
system allows patients to make
bookings at a time to suit them and to
choose from a large number of possible
appointments. Requesting repeat
prescriptions is equally convenient.
Furthermore, an icon against each
item in the list of prescriptions which
appears on the screen links to an
approved website with information
about that particular item, and on to
other websites which discuss how it is
applied to different groups of patients.
Patients are quoted as saying that they
learned more in five minutes by using it
than in all the consultations they had
had with doctors.
The record itself shows any
allergies, current medication, clinical
problems in reverse chronological order,
clinical problems by body system,
family health history, most recent entry
on record, most recent results and
summaries of all recent consultations.
If printed out or accessed online, the
list of problems would be extremely
useful if the patient required emergency
care. Not surprisingly, lessons learned
with this record are influencing the
development of the summary
care record.
A diabetic patient’s record might
include information about the patient’s
lifestyle as part of their consultation,
and could show a list of tests to be
carried out which would be of interest
to other health professionals like
pharmacists, opticians and dieticians if
the patient chose to discuss their case
with them.
The ability to view test results is
very popular with patients. If the
results are normal (which they very
often are), there is no need for patients
to make another appointment with the
doctor just to obtain their results.
Letters are visible
Any letters concerning the patient are
also attached to the record, so the
patient can be aware of their content.
Previous medications are also visible –
meaning that if a condition recurs, a
patient can request a medication that
helped them recover from it in the past.
Again links are provided to sources of
information at various points within
the record.
Dr Hannan quoted many cases
where having access to their record has
been of direct benefit to patients, not
least in correcting errors and
prejudicial comments which had in
some cases been in their record for
years.
He also noticed teenagers helping
their grandparents with IT, and in
return becoming more aware of the
long-term effects of lifestyle on health.
So the main opportunities of
records access are that it can help
foster a partnership of trust between
patient and doctor, improve patients’
health literacy and help them take
ownership of their illness.
Some other advantages are that
it could:
Free up doctors’ time.
Help promote practice-based
commissioning.
Support a shift in management of
care from secondary to primary care
where appropriate.
Provide more cost-effective
healthcare by making better use of
other health professionals.
The challenges are complex but fall
into five main areas:
Patient consent – implicit or
explicit? Under what circumstances
should information not be made visible?
Risk management and governance –
what structures should be in place?
Drivers for change – what are they
and is society ready for the challenge?
Privacy, confidentiality and security
– how do we get the balance right?
The challenge of technology and the
digital divide – is it unfair to people
who can’t access the internet? How can
the records access join up with other
services and initiatives in the NHS?
Discussion
Are doctors concerned that patients
might become too empowered and take
up too much of their time? Dr Hannan
felt that the opposite was true – patients
using the service found out more for
themselves and took up less time.
At present 300 patients out of a
total of 12,000 patients in the practice
have signed up for records access – this
represents a considerable success in
absolute terms but is still a small
percentage of the total. Does that
represent reluctance on the part of the
majority of patients to take
responsibility for their care, or is it just
the standard response to innovation
where the early adopters engage first
and the rest follow later? Will some
doctors be slow to embrace records
access because they feel threatened by
this new relationship with patients?
There are no easy answers, but the
conclusion seems to be that patient
access to medical records offers
tremendous opportunities and some
challenges. It will work, but will take a
while and will need a basic shift in
attitude from both doctors and
patients. If the right checks and
balances are in place, it will make life
easier and safer for anyone receiving
treatment in the NHS.
25
Forthcoming events
April
ASSIST North West Branch
3 April, 2pm
How to obtain maximum value from consultants
Speakers: Nadine Fry and Julian Todd, Tribal Consulting
Wrightington Conference Centre
www.bcs.org/assist/northwest
Northern Specialist Group
8 April
Date, title & speaker TBC
Manchester Conference Centre, University of Manchester,
North Campus, Sackville Street, M1 3BB
www.bcs-nmsg.org.uk
IHE-UK with BCSHIF
9 April, 10am-6pm
Sharing Clinical Documents and Integrating Workflow
St Catherine’s College, Manor Road, Oxford
www.bcshif.org
Health Informatics Forum seminar
9 May, 12.30pm for 1.30pm
Topic to be confirmed
BCS, 5 Southampton Street, London
To reserve your place email [email protected]
ASSIST North West Branch
13 May, 2pm for 2.30pm
GP systems of choice and GP to GP transfer programmes
Speakers: Peter Dyke, Connecting for Health industry liaison
manager + another to be confirmed
The Sedgley Room, Harrop House, Prestwich Hospital
http://northwest.assist.org.uk
ASSIST National Conference & AGM
22 May
London TBC
www.assist.org.uk
June
HC2008 – An invitation to the future
Northern Specialist Group
25th Annual Conference and Exhibition
21-23 April
Conference organised by BCS Health Informatics Forum
Exhibition organised by BJHC
Harrogate, North Yorkshire
www.bcs.org/hc2008
12 June. 6.15pm for 7pm
Electronic prescribing
Presenter: Bob Hammond, programme communication lead
and/or Ann Slee, ePrescribing clinical lead,
Connecting for Health
Manchester Conference Centre, University of Manchester,
North Campus, Sackville Street, M1 3BB
www.bcs-nmsg.org.uk
May
ASSIST North West Branch
ASSIST Yorkshire Branch
1 May, 12.30pm for 1.30pm
Parkside Room, John Charles Centre for Sport , Middleton
Grove, Leeds, LS11 5DJ
http://yorkshire.assist.org.uk
Northern Specialist Group
8 May, 6.15pm for 7pm
Electronic referral and discharge letters including
social services
Speakers: Tom Rothwell, managing director, Medisec
Software and Debi Lees, IT project manager & business
analyst for the Cheshire ICT Service
Manchester Conference Centre, University of Manchester,
North Campus, Sackville Street, M1 3BB
www.bcs-nmsg.org.uk
26
24 June, 2pm for 2.30pm
IG controls enable data sharing and meet the
care record guarantee
Speakers: Charles Yeomanson, information governance
architect, North Midlands and East Programme for IT
Technology Office, Connecting for Health
http://northwest.assist.org.uk
July
Primary Health Care Specialist Group
Summer conference
1-2 July
Chesford Grange, Warwickshire
www.phcsg.org.uk
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Keep your
career
on track
MTG/AD/376/0108
As a committed Health Informatics professional you know how important it is to be up to speed
with the latest developments. Keeping your career on the fast track is equally important. When
you join BCS you’ll be doing both. Membership gives you the support of a wide network of
like-minded professionals and immediate access to a growing range of services and benefits to
keep you ahead of the field at every stage of your career.
Achieve professional recognition and all the rewards
that go with it. Visit www.bcs.org/membership
Alternatively, call us now on 0845 300 4417
BCS IS A REGISTERED CHARITY: NO. 292786
8 31 e
00 D ntr
C2 and Ce
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t
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at l, S na 08
us pri atio c20
A r n /h
sit
Vi 3rd nte rg
I
.o
-2
st ate cs
21 rog w.b
ar ww
H
Keep your
career
on track
MTG/AD/376/0108
As a committed Health Informatics professional you know how important it is to be up to speed
with the latest developments. Keeping your career on the fast track is equally important. When
you join BCS you’ll be doing both. Membership gives you the support of a wide network of
like-minded professionals and immediate access to a growing range of services and benefits to
keep you ahead of the field at every stage of your career.
Achieve professional recognition and all the rewards
that go with it. Visit www.bcs.org/membership
Alternatively, call us now on 0845 300 4417
BCS IS A REGISTERED CHARITY: NO. 292786