Prescriptions is a blog at Cheap Cialis Blogger

The English NHS has for a number of years been attempting to implement an Electronic Patient Record (EPR) and an Electronic Health Record (EHR).

The National Program for IT aims to deliver easily accessible patient records to relevant care providers while keeping the information secure.  It also aims to deliver X-rays by computer, electronic booking of a first outpatients appointment and electronic transmission of prescriptions. (NAO report 16th of June 2006)

This is to be delivered over a timescale of 10 years.

The NAO claims that areas of this program are on track.  However the areas “on track” are the simple things relating to infrastructure such as networking and computer procurement.  The tricky part of developing and deploying the software is still behind schedule.

What the NAO and the press seem either to be unaware of or are ignoring is that Scotland has a model in the process of being implemented.

The Current Scottish Model

In Scotland the NHS set up an Executive level “task force” called the “Electronic Clinical Communications Initiative” or ECCI (pronounced rather unfortunately like the street slang for Ecstasy - “eckie”).  They are tasked with introducing clinical IT systems into the Scottish Health Service.  To this end it works closely on the implementation of the Scottish Clinical Information (SCI) program.

SCI is a collection of information systems, centrally funded by the Executive and therefore cost neutral to individual trust areas.  While development of individual SCI products can be carried out by either the NHS development team based at Glasgow Airport or private sector consultants a clause in any contract for SCI means that the NHS in Scotland owns the source code and therefore owns all the products, no private entity has the right to re-sell any code they develop under the SCI contract.

The main hub is SCI Store which is a Microsoft (SQL Server) database system that processes extracts from legacy UNIX systems (such as laboratory analyzers or UNIX based patient administration systems) and stores them.  Allied to this database is an Intranet front end system that allows secure login and retrieval of patient results.  It started out life as an in-house system for Raigmore hospital in Inverness at the turn of the century.  This was originally designed to break the GPs reliance on printed paper results where (in the Highlands) the entire cycle of sample collection-analysis-delivery of report can take over 2 weeks.  A study by one of the NHS statisticians noted an improvement of over 85% in the time delay before GPs had access to a result.  Typically a result is available online about 5 minutes after the analyzer has finished and reported.

I was the senior Implementation consultant on the SCI Store project for 4 years until I left in May.

Store exposes a number of “web services”.  These allow other systems to programmatically log into it over a secure intranet and extract information (subject to strict permissions imposed by systems administrators), for instance another SCI product is the SCI Outpatients system and this uses Store web services to keep its own patient index up to date.  Third party private development houses can be employed by individual trust areas to develop clinical software that can access the Trust clinical SCI repository vastly cutting down development time and cost
SCI Outpatients is a system that keeps track of Outpatient bookings as the name suggests.  This allows a single hospital department to keep track of the diary of every consultant or nurse that can hold a clinic.

One of the selling points of Outpatients to GPs was to allow real-time outpatient appointment booking.  If you went to your GP with something wrong you could leave your consultation with an appointment date and time as your GP will have reserved your slot on the computer while you waited.  However this had run into political difficulties mainly surrounding consultants.

Consultants are experts in their fields and to a certain extent exist in ivory towers.  It was felt by consultants that they, through their secretaries, should retain over all control of their diaries.  To let a mere GP book slots may ruin a tee-off time they had planned.  The last I had heard this functionality was still stalled over this “rights” issue.

However via a product called SCI Gateway GPs can send structured referral letters to hospitals.  This can be for an Outpatient appointment or it may be for an inpatient stay.  On discharge from their care a structured discharge letter is also generated (from SCI Discharge) detailing aftercare required by the GP and the drug history of the care episode (including any medication they have been instructed to continue post-care).

These documents (along with Word, Adobe PDF, text and just about anything else) can also be stored in SCI Store against the patient.  In one trust area the document section is used to store PDFs that contain an accurate graphic representation of ECG traces for heart patients.

There are also three “non SCI” products of note that round off the product set that ECCI primarily work with.

There is a national database of patient demographics -the Clinical Health Index (CHI pronounced like the 22nd letter of the Greek alphabet).  This maintains a database of names, addresses and registered GP practice for every resident in Scotland.  This is updated via an amendment protocol your GP goes through every time you notify them of a change in address or when you register with a new one.  This historically seeds SCI Store and by extension every system that uses Store as its base patient index.

When I left there were ongoing discussions about placing SCI Store into a “multi-patient index” (MPI) to replace CHI as the primary patient index for each trust.

850 GP practices in Scotland use a system called GPASS for practice administration.  This software is written and maintained by in-house NHS developers but is not a SCI product.  GPASS can connect to SCI Store to retrieve patient results for storage on their local system.

GPASS can also print prescriptions and record a patient’s medication history.  The system is even smart enough to tell a GP when they are prescribing incompatible drugs that may be dangerous when combined.

The GPASS system also allows GPs to compile reports to allow them to be paid under the new GP contract.

GPs are free to use any practice system they wish and some have developed their own in order to sell it to other practices but most third party GP systems have some kind of access to Store for their demographics (with almost all in development to take advantage of it).

Finally there is the Emergency Care Summary (ECS).  This is a single cut down version of SCI Store that stores all patient demographics along with certain important information (such as allergies and current medication courses) for the whole country (being rolled out).  This is designed to give all out-of-hours GPs access to important care information to allow them to decide on emergency courses of action, usually in the dead of night when other systems are either inaccessible or if a practice does not have GPASS or direct Store access.

Historical English Solutions

For a good number of years the NHS in England operated on a Silo development mentality.  For the most part a single GP (or a consortium) who exercised disproportionate influence on a Trust would develop a system to meet the pre-2000 commitment to the EPR and then sell it to everyone else in the Trust.  Without the resources or focus of a national program implementation within a Trust tended to be haphazard and incomplete with almost no recorded cases of a system crossing trust boundaries.

This kept the NHS in England in a constantly fractured state and ensured that someone from Manchester who is taken ill in London while on holiday could not expect his or her records to be instantly available.

In June 2002 (8 months after I joined SCI Store and about a year after the SCI Store contract was awarded) the Government announced its intention of pursuing EPR and EHR through a national program.

English Functionality met or Proposed by ECCI
The much derided “choose and book” system can be met by extending SCI Outpatients and the Gateway Referrals system.

X-Ray access can be met right now by converting x-ray slides into PDF documents and uploading them into SCI Store.  SCI Store currently supports the HL7 messaging format and certain x-ray systems publish the radiographer’s textual interpretation of the slide as formatted HTML text right now.

Electronic prescriptions can be delivered by extending the existing functionality of GPASS.  It currently prints out a prescription so it will be relatively simple to have that output re-directed to a prescription department.  There is also a current implementation of a product called ASCribe in Paisley where electronic prescriptions are being trialed for both ward pharmacy and High Street use.

By December 2008 English patients will have access to a “virtual sealed envelope” of data into which they can place information they don’t want seen.  SCI Store implemented this in February 2006 with version 2.2 of the software in compliance with the Data Protection Act.

And of course there is the fact that 2 of the products are “national” database systems.  Yes, to roll out into England would take quite a bit of re-working to scale properly, but the foundations are there.

English Functionality to Improve ECCI

Smart card access to the full range of products would be a definite improvement but as the product set is disparate and localized (each trust has its own implementation of Store and Outpatients over which it dictates security and access protocols) at the moment it would require harmonization of the administration.

Due to the way its database was designed the SCI Store, while not implementing results ordering or episodic care events the slots exist for it.

Duplication of Effort

The “Choose and Book” functionality and the clinical letters for both referral and discharge are the most obvious examples where both English and Scottish health services are working on the same thing at the same time.  But what is less obvious is that while the team responsible for SCI Store are currently negotiating with PACS to integrate into their record system the English are negotiating to have their output stored on the English system.

Conclusion

It is a matter of public record that duplication of effort occurs in both projects but the fact that the Scottish project, by virtue of its size, is streets ahead of the English one should mean that it is more cost effective to combine projects at this stage.

Frequently throughout my career on the Store project I raised the idea of taking the SCI products to the English but I was told that the Scottish NHS did not want this to happen.  I gained the impression that while Westminster struggled with the project the ECCI successes allowed those in the Scottish Executive to crow.  They are using these two projects in a game of career one-upmanship.  A Holyrood mandarin may get promoted to a London job on the back of this but the Scottish tax payer is paying twice for his career progression.

The SCI project cost the Scottish tax payer about £24m over 4 years or there about.  The English model is going to cost every tax payer in the UK £6bn.

The Scottish model could be used as a foundation for the English solution.  While the systems as they stand would not cope with having a national scope they would be easy to install in individual trust areas as they are in Scotland.  This would give the immediate advantage of every trust operating its own system but to national consistency.  Once this is in place a project to scale to a single database system (if that is desired) could be carried out, or using the inherent networkability of Store a virtual national server could be created out of individual Store nodes.  The rest of the product set could be deployed in a similar fashion.

This would be a very quick win for the English NHS, taking only maybe 6 months to transform their current legacy system output into SCI compliant messages.  Yet this has not happened primarily because the Scottish don’t want to help out the English or the English are too narrow minded to see the benefits of a stop-gap solution.

Even in the media this option appears to have passed people by.  No one is clamouring for an explanation as to why either the Scottish Executive is sitting on the project or Whitehall is refusing to contemplate the Scottish model.

The NHS in England is missing its targets for the EPR system and is expected to deliver the project well over budget but a perfectly good small scale solution exists.  And its closest implementation is Melrose General Hospital.

Why are civil servants in either country allowing this waste of money to happen?  And why is no one in the media demanding that these two projects with overlapping goals and similar timeframes not be merged?

Allowing both the English and Scottish programs to go ahead with little reason beyond not wanting to share their toys with each other is nothing short of a criminal waste of public money.  Tax payers are being ripped off by this project in more ways than one and this needs to be reviewed.

Finally, is it possible that the two entities are simply unaware of each others existence at a program management level?  Lets see…

Contractor developing Choose and Book – Atos Origin
Contractor developing SCI Store – Atos Origin