Implementing Information For Health: Even More Challenging Than Expected?

Implementing Information For Health: Even More Challenging Than Expected?
IMPLEMENTING
INFORMATION FOR HEALTH:
EVEN MORE CHALLENGING THAN

EXPECTED?
Submitted To: Dr. Peter Drury

Head, Information Policy Unit
Department of Health
Dr. Gwyn Thomas

Acting Executive Director
NHS Information Authority
Submitted By: Professor Denis Protti

School of Health Information Science
University of Victoria
Victoria, British Columbia, Canada
Date: 11 June 2002
FINAL COPY 11-J U N -02 P AGE 1

TABLE OF CONTENTS
1 MANAGEMENT SUMMARY......................................................................…………..... 4
2 BACKGROUND ...............................................................................……………………... 12
2.1 Introduction …………………………………………………………………………… 12

2.2 Acknowledgements and Apologies .........................................................................….... 13
3 ENVIRONMENTAL SCAN .............................................................................................. 14
3.1 Government Policies and Direction ................................................................................. 14

3.2 Service Reaction and Response ……………………………………………………….. 15
3.3 NHS Direct ……………………………………………………………………………. 17
4 INFORMATION FOR HEALTH ..................................................................................... 20
4.1 Introduction …………………………………………………………………….……… 20

4.2 Political Expectations and Pressures ............................................................................... 21
4.3 Accomplishments ……………………………………………………………………… 22
4.4 General Observations ...................................................................................................... 25
4.5 ERDIP Lessons Learnt To Date ...................................................................................... 29
4.6 ERDIP and The Consent Issue ………………………………………………………… 31
4.7 The 24-hour Emergency EHR ..................................................................................…... 33
4.8 The Electronic Health Record Strategic Outline Case .................................................... 34
6 RECOMMENDATIONS ...............................................................………………………. 37
6.1. Harmonise the many performance management targets ….………………………….. 37

6.2 Bring together all of the EHR-related initiative leaders …………………………….. 37
6.3 Revisit the Information for Health targets ………………………………………….. 38
6.4 Revise the level 3 EPR targets ………………………………………………………. 39
6.5 Refocus the EPR-EHR model ……………………………………………………….. 40
6.6 Develop a broker model to address the political need for an ‘Emergency’ EHR …… 42
6.7 Advise the field to concentrate on the basics ………………………………………... 45
6.8 Address the patient consent issue …………………………………………………… 47
6.9 Mandate a standard that all NHS computer systems have an audit trail …………….. 47
6.10 Develop a Knowledge Management (Learning) Programme …………………...…... 48
6.11 Revise the Requirement for Accreditation (RFA) …………………………………... 49
6.12 Let NHS Direct get on with their agenda ……………………………………………. 50
6.13 Push for a CIO position in the new Strategic Health Authorities …………………… 50
6.14 Investigate the appointment of integrated care case managers .……………………… 50
7 CONCLUSION …………………………………………………………………………... 52

APPENDICES
A - IPU Remit
B - NHSIA Remit
C - People Interviewed
D - Documents Read and/or Reviewed
E - EHR-Related Initiatives
F - ERDIP Reports
G - Early Findings From The ERDIP Sites
H - Comments on the EHR Strategic Outline Case
I - The 8W’s Minimum Dataset
J - Events EHR

1. MANAGEMENT SUMMARY
Introduction
Over the period 6th August to 19th October 2001, and at the invitation of the heads of the Information
Policy Unit (IPU) of the Department of Health and the NHS Information Authority, I once again
visited England to review the state of progress of Information for Health, taking account of the
implications of the emerging changes within the UK health care system.
Returning to the UK, it did not take me long to realise that the NHS was once again in the midst of a
significant period of transition. It was evident, even to an outsider, that the United Kingdom has a
Government which believes that the NHS has to be re-organised and made to be more equitable,
accountable, and customer-focused. I sensed that it is a Government that is looking for obvious
progress in reforming the public sector - spurred on in particular by negative media coverage about
the NHS.
In its recent policy document, Shifting the Balance of Power in the NHS (StBOP), the Government
expresses its desire to devolve power and decision-making down to the frontline, to decentralise, to
provide patients with choice, to give local staff the resources and the freedoms to innovate, develop
and improve local services. This desire pervades the changes I observed and sets the tone for my
report – these are fascinating, if somewhat daunting, times for the NHS.
Credit for any valuable ideas in this report should go to those whom I interviewed and to those who
wrote the excellent reports and e-mails that I was made privy to. I am deeply grateful to all of them.
Without their candor and insights, my modest efforts would be academic to the extreme. I regret that
in keeping with my promise to not name names, I am unable to publicly acknowledge a number of
people who I think have a clear outlook on the course of direction and understanding of what should
be done.
I accept full responsibility for any and all errors of omission and commission and for any
thinking which some may consider to be too radical or politically unacceptable. I appreciate that
many of the Ministerial commitments have to be taken as ‘givens’. However if a train is headed
down a track where a bridge in the distance may collapse, it is surely to everyone’s benefit to be
forewarned.
In trying to tell it as I see it, I am acutely aware that others may see things differently. In this type of
work, one is constantly reminded of Disraeli’s remark, "It is easy to be critical but difficult to be
correct".
Celebrating Success
It is important to acknowledge that much has been achieved since Information for Heath was
announced three years ago. Everyone involved, from those within the Department of Health and the
NHS Information Authority to those operating at the coal face should be proud of what has been
accomplished to-date. Even the harshest critics would have to be pleased with key pieces of
infrastructure that are either in place or close to being delivered.
Particular pride should be taken vis-à-vis the use of computer technology in GP practices - even if the
critics will argue that more should have been achieved. According to the 1st October 2001 issue of

Harris Interactive Health Care newsletter, 59% of primary care physicians in the United Kingdom,
and 52% of those in New Zealand, use an electronic patient record while a mere 17% of U.S. primary
care physicians claim to do so. An impressive 87% of U.K. physicians claim to use electronic
prescribing as compared to a lackluster 9% of U.S. physicians.
Information for Health
When it was announced in September 1998, the Information for Health strategy was acclaimed, both
within the UK and abroad as visionary, appropriate and relevant to the needs of the NHS. It was seen
as a solid attempt to connect key national health policies with the capabilities of modern information
technologies. It argued that the key to effectively supporting clinicians in day-to-day care delivery
was electronic records and that it was important to recognise that little could be accomplished until the
underlying information and communications technology infrastructure was in place. It was a national
strategy that was to be implemented locally – an approach that was intended to foster a learning
organisation by building the information capacity locally where most information is processed and
where the information must come from for all other initiatives.
Most saw the strategy as an honest and pragmatic attempt to build upon the work of the early 1990s.
What few criticisms there were centered on vaguely worded targets, an aggressive timetable, and the
challenges to be faced around "changing the culture". Information for Heath garnered significant
national attention but the early optimism turned to doubt as it transpired that the aggressive objectives
would not likely be attained due to the problems of modernizing the existing infrastructure, the
scarcity of existing capabilities, the cumbersome procurement issues, as well as the context of fast
moving policy and culture changes.
By late 2000, in response to developments both internal and external to the NHS, an update to
Information for Health - Building the Information Core – was issued to reflect the changing NHS
priorities as set out in the NHS Plan, as well as the new e-government strategy. It is now almost 2002,
half way through the life time of Information for Heath and I – and indeed many of those I spoke with
– believe that a further update is needed - an update which more directly takes into account the wide
range of new organisations/programs and business initiatives which have, in varying degrees,
significant implications on the information management and technology (IM&T) agenda.
There is a clear sense of urgency about Information for Heath; it was palpable. It consumed most of
my discussions - little time was spent reflecting on achievements and learning what has worked and
not worked in the past 3 years. What seems to be ignored, or at least overlooked, is that much of
Information for Heath is about infrastructure.
Delivering the Infrastructure
Infrastructure breeds impatience. It is important to note that the provision of infrastructure services is
an enabling mechanism. The infrastructure itself will deliver some benefits, but the main outcomes
will be achieved by the provision of additional applications and services.
As with any infrastructure, information technology infrastructure does not provide direct business
performance. Rather it enables other systems that do yield business benefits. IT infrastructure is
strikingly similar to other public infrastructures such as roads, hospitals, sewers, schools, etc. They are
all long-term and require large investments. They enable business activity by users that would
otherwise not be economically feasible. They are difficult to cost-justify in advance as well as to show
benefits in hindsight. They require a delicate investment balance - too little investment leads to

duplication, incompatibility, and sub-optimal use, while too much discourages user investment and
involvement and may result in unused capacity.
Initiatives and targets
In my review last year, I commented that the NHS was in ‘initiative overload’. This year, it would be
safe to add that the NHS is also in ‘target overload’. The number of targets and expectations on the
service appear somewhat onerous. Targets are everywhere - the NHS Plan, NHS Cancer Plan, the
National Service Frameworks, Out of Hours Review, and the Local Implementation Strategies to
name but a few.
Even if the IM&T is accepted as one of the main underpinning platforms for a modernised NHS, I
fear that the information agenda is at risk of being diverted by the performance management agenda
as a result of, the emphasis on star ratings, NHS Plan targets (though these include IM&T targets, I
would suggest that they are seen to be less important to most Chief Executives) and a raft of other ‘my
job as Chief Executive is on the line” targets.
I could not help but sense that many parts of the NHS are feeling beleaguered, micro-managed, under-
funded and suffering from a surfeit of “changeitis”. Many feel that they are constantly in response
mode – particularly to requests from the Centre, from Task Forces, etc. Few would argue with the
objectives of the performance management targets - it is more about the number of them and the pace
of change. Some would argue that there is an inconsistency between the empowerment rhetoric in
StBOP and the day-to-day realities of performance management monitoring.
In my opinion, there is a pressing need to reduce the number of developments and initiatives. It would
be wise to focus down on a number of key initiatives in the next two years to bolster confidence in
what is being done by making demonstrable improvements for NHS staff and patients.
There is a need to explicitly tie all of the “information-related” targets more closely to the business
needs and targets described in the NHS Plan and elsewhere. There is an equally important need to
work out what the "corporate NHS" can afford to do – and what work, laudable though it is, simply
cannot be justified and diverts attention and resources from the ‘drop dead’ priorities. There should be
an implementation plan that brings together best guess costs for the implementation of any target. If it
is known what is available to spend and what the cost of achieving each target is expected to be, then
the Centre can make sure that they are not promulgating unrealistic expectations that cannot be
funded.
Perhaps my most contentious recommendation is that the Department of Health should acknowledge
that, for a variety of real and very valid reasons, a number of the original Information for Heath
targets are no longer achievable in a meaningful way and should be revisited. There is no shame in
this, indeed it is a sign of a mature organization that can reflect and adapt to its changing environment
- is it better to fail on time or succeed later?
It is also important, in my view, to synchronise the policies and messages emanating out of the IPU,
the NHSIA and the Primary Care Branch of the Department of Health. In my opinion there is
confusion as to who holds the policy responsibility for many of the existing initiatives. There
continues to be uncertainty as to who should be out regularly 'beating the drum' and actively
promoting Information for Health (IfH) throughout the Service.

The importance of these three entities working in complete harmony should be acknowledged to be
one of IfH’s most important critical success factors. The same synchronicity and partnership should
be evident from Health and Social Services.
Shifting focus
One of the many observations I made this year was the apparent shift from the primary intent of
Information for Heath in supporting day-to-day clinical practice to one of collecting data for
retrospective analysis such as clinical governance. The original intent of Information for Heath was
akin to providing parents and their children with the means to make their lives more productive and
satisfying. The apparent shift in priorities seems aimed at providing friends, counselors, and
government agencies with information that they can use to help parents and children understand their
state of affairs and behaviors. Both sets of communities have important needs; the challenge is
deciding which ones to concentrate on given the political realities of the day.
The current state of affairs has a comparable, and uncomfortable, feel to when the 1992 IM&T agenda
was ‘hijacked’ by a political imperative to move to an internal market and establish systems to
manage competition and contracts.
It was most disconcerting to learn that 70% of the hypothecated funds intended for investment in
IM&T in the 2001/2 national allocations were diverted to other purposes. If this problem persists in
2002/3 the NHS will fail to deliver key Information for Health objectives, particularly the
development of electronic records, and this will undermine the clinical modernisation agenda in the
NHS Plan. If it happens again, Information for Health will be irrelevant.
Another observation that caused me some anxiety was the apparent lack of organisational learning
that is so critical to long-term success. I found little evidence of anyone bringing together the many
lessons being learnt - one of the original intentions of Electronic Records Development and
Implementation Programme (ERDIP). Based on the material available on the ERDIP web site, I do
not feel that the reason that some sites may fail to achieve the key deliverables outlined in their project
briefs will be because of the lack of national standards. Rather, it will be other issues such as
insufficient attention to the change management process, poor system supplier co-operation, lack of
clinician commitment and buy-in, lack of resources, etc. Who is analyzing and evaluating this
material, and feeding it back to the NHS in accessible, timely and manageable ways?
The consent issue
The one standards-related area that may be a very real barrier to the ERDIP sites and indeed the whole
NHS achieving their key deliverables is around the issue of informed patient consent and who has
access to which portions of the electronic records. As stated in the Population Records Strategic
Outline Case, whilst there is huge potential to make better use of personal data to deliver benefits to
the public, this will only be realised if the public trusts the way in which the public sector handles
their personal information – which means meeting their rights and legitimate expectations on the
protection of personal privacy. Even if part of the final solution is revised legislation, it seems evident
that in some form or other, the consent process is going to have to be automated. The National
Information Policy Board, in conjunction with the Privacy Commissioner’s Office, should
aggressively pursue resolving this very important issue.
One legal opinion was given that a number of bodies are currently exposed to a degree of legal risk in
relation to patient records. Many of these organisations may be unaware of their duties and obligations

under the law in respect of patient records. They may also not fully appreciate the implications of
breaching them. It should not go unnoticed that negligence claims against NHS hospitals in England
have risen by £700 million in one year, to an estimated £3.9 billion - almost 10% of the annual NHS
budget 1999-2000 for England of £40.1 billion - according to the May 2001 National Audit Office
Handling Claims for Clinical Negligence report.
While not an answer to the fundamental need to address issue of informed patient consent, I feel that a
tremendous amount of public and professional anxiety would be dissipated if all NHS organisations,
regardless of whether they are in primary care, secondary care or elsewhere, were regularly recording
who is accessing, including viewing, what data. In addition, all organisations should be expected to
make use of the audit trail data to monitor who is accessing what data.
This process need not be resource intensive or time consuming. Every night, each system could
produce a report of ‘unusual’ occurrences – based on predetermined algorithms. If someone, such as
the Caldicott Guardian was required to look and act upon the report the next morning, even if they
only randomly selected 3-4 to pursue, the number of incidents of ‘browsing’ would drop overnight.
The Department of Health should issue guidance on this subject as soon as possible.
Electronic records
I find it difficult to provide explicit guidance to the primary/community (non-hospital) sector in

selecting and/or upgrading their EPR and information systems, as there is no single common
organisational community model. Can anyone realistically at this time advise these groups to build
their EPRs based on adaptation of GP systems, on community health systems, social services systems
or even on acute Trust systems? There are many potential directions of travel and any given one may
not be ‘the best’.
Appreciating these limitations, there is still sound advice that can be given which applies to any
organisational model. NHS organisations should cooperate with as many organisations in their local
health economy as possible in order to facilitate greater sharing of patient data. At a minimum, they
should ensure that there is a collaborative planning process - through the Local Implementation
Strategy or its equivalent. They should make certain that sensible first steps are taken such as
encouraging PCTs to consolidate the range of GP practice systems, realising that gaining and
retaining clinical commitment is so important that anything that puts that at risk has to be looked at in
terms of the pain/gain ratio. Clinicians are more interested in Return on Time (ROT) than they are in
Return on Investment (ROI), even if accountants prefer the latter.
When it comes to the Electronic Health Record (EHR), there appears to be a case for more clearly
defining the business needs. Is the priority of the Electronic Health Record to be the tool to assist in
the day-to-day delivery of care and prospective support - particularly the so-called “emergency care”?
Or is its main intent to be providing the data to support clinical governance and other retrospective
analysis? Answering this question one way will lead the journey in a very different direction than the
other – even if the two paths will eventually end up at the same destination.
There is clearly great emphasis on the use of the Electronic Health Record to support emergency – or
unplanned care. Access to emergency care data will bring significant advantage to some – but only a
relatively small minority of clinicians and patients. There is a real danger that the relatively limited
advantages of the interim emergency care solution will be insufficient to drive the required changes in
NHS practice necessary to secure the full benefits of EHR implementation.

In order to address the political pressure for an ‘Emergency EHR’, I have recommended that the NHS
Information Authority be directed to make patient medication data available to all authorised Accident
and Emergency clinicians, NHS Direct nurses and Out-of Hours GPs via an ‘Events EHR’ as soon as
possible. They can build this new functionality on one of the most solid and reliable foundations the
NHS has, the “Exeter” system. It would take immediate advantage of the fact that GP systems already
electronically send data to Exeter.
Although one of the aims of the Exeter system is to support patient registration in the context of GP
reimbursement, I do not believe that it would be a major technical or cultural change to also have GPs
send to the Exeter system details of the patient’s allergies and medication data – data that is currently
captured in many GP systems. This medication data would then be made available to all authorised
‘emergency’ personnel – with an accurate audit trail of who accessed what. It could also prove very
useful for clinical governance – particularly in terms of chronic disease management and the analysis
of repeat prescriptions. Ideally this new functionality should be fully integrated with the Electronic
Transmission of Prescriptions project and make use of a single national drug dictionary, part of the
national infrastructure.
It was more evident to me this year than ever before that someone from the “business/deilvery side”
of the NHS – someone who is able to traverse traditional sectoral boundaries - has to take ownership
of the totality of the “electronic records” initiative. It should be an individual committed to actively
supporting a strong project management and change management agenda. Some would argue that the
individual should be a clinician. What is clear is the overwhelming evidence that those who will
ultimately benefit from them - rather than the information management and technology professionals -
must lead information systems initiatives. The role of the latter should be to support and advise, not to
lead.
As well as re-energising the push for electronic records with clear user leadership, I also believe that
the Department of Health, in active partnership with the NHS Information Authority, should reframe
the existing Electronic Patient Record and Electronic Health Record targets into a new set of
unambiguous targets that relate to providing specific functionality, e.g. results reporting, across the
entire care spectrum of primary, secondary, community, mental health, and social care environments.
The original concept of the EHR being a longitudinal health record about an individual is still very
valid! However, it has become entangled in organisationally bound thinking. A true patient-centric
model is needed. The aim should be to avoid the disruption that occurs as a result of organisational
restructuring. A new paradigm is needed to support the single assessment process outlined, as an
example, in the NSF for Older People – one that recognises that many older people have health and
social care needs, and that agencies need to work together so that assessment and subsequent care
planning are person-centered, effective and co-coordinated.
If a conceptual mind shift does not take place, there is a grave risk that both the EPRs and the EHR
will be built on increasingly obsolete concepts of inpatients and outpatients; historic models of face-
to-face, hospital-based, consultant-led service delivery; and existing organisational boundaries. They
will not meet the challenges being faced of multi-professional, multi-organisation patient pathways,
NSFs and clinical networks. The EHR needs to be a patient/client record that is independent of the
institution providing care at a point in time along the patient/client pathway(s). This would seem to be
in line with “an NHS designed around the patient”.
There is a clear national policy aim of the integration of services across health and other public
services, most notably social care. In some fields - especially mental health/learning disabilities -

NHS staff is increasingly working from local government premises and vice-versa. In some cases
service is the responsibility of one party but largely delivered by another. However a very practical
issue arises when local attempts to ensure staff have access to the network services they need run up
against the NHS network connectivity rules. This will raise the debate about the inequality of funding
and performance management arrangements and different policies - for example where local authority
staff are not allowed access to the Internet, while their NHS colleagues working as part of the same
team are.
This brings up the question of where the NHS boundary lies and whether the concept of a NHS-only
network has any meaning in the future – particularly given that local authorities will be pushing for
networks, which crisscross traditional boundaries. As reported last year, some are of the opinion that
the Internet will become the common vehicle – even for ‘confidential’ communications.
NHS Direct
I observed the growing consensus that NHS Direct has the potential to become a truly integral part of
the NHS – some would argue it has already proven itself and will only get better. I would have to say
that the Government has got this one right, i.e. an evening, weekend and holiday service to assist
British citizens with any unplanned health ‘crisis’ that they encounter – even if there are still some
GPs who remain to be convinced that it will help them. I believe that NHS Direct provides a bona
fide opportunity to realistically redesign the way care is managed and delivered.
Although I did not spend a great amount of time in and around NHS Direct, nonetheless I am of the
opinion that they should not be burdened with the development of Electronic Health Record (even the
emergency aspects of it) at this stage of their existence. NHS Direct have enough on their plate
developing the decision support aspects of the Clinical Assessment System as well as merging their
databases. They should be focusing their energies on integrating their services with Out-of-Hours
services – all very important capabilities needed to make their service all that much more valuable to
the public and to the NHS.
Knowledge and learning
Knowledge Management is about creating a learning environment where knowledge sharing is part of
the culture. Learning is fundamental to enhancing local creativity and national cohesiveness. In a
data-intensive service such as healthcare it is a “must have” - not a “nice to have”. It is critical to
information sharing and a common direction. The NHS needs tools to support real knowledge sharing
so that it can become a real learning organisation based on evidence of what works and what does not.
Otherwise, the result will be fragmented systems. The NHS Information Authority, through the
auspices of the National electronic Library for Health, and in conjunction with the e-envoy’s office,
should rapidly progress with this important initiative.
Conclusion
At the end of the day, it is people, not technology, that make the difference between success and
failure . When end users want to make information technology tools work for them, even "poor" tools
can deliver real business value.
Failure to realise value is seldom due to a tool's need for changes but to a mindset that is not
motivated to work with the tool as it is. Configuring technology tools requires changes in the way
work is done - by users and to business processes. Imagine a group of lumberjacks using chainsaws

the same way they did handsaws by sawing back and forth. They would certainly use the chainsaws
differently than handsaws, but they would not automatically know the best way to use the new tools.
IT tools are no different. When the tools change, the people and the business processes must adjust.
Business value increases when users are determined to work with the new tools, but the value
decreases when the users are not motivated.
Much research has been done in an attempt to identify the key factors that predict EPR/EHR
implementation success. Over 150 factors have been identified, but only two, "top management
support" and "user involvement" are consistently associated with successful implementations. Several
additional key elements have been repeatedly identified:
• Local champions must actively and enthusiastically promote the system, build support,
overcome resistance, and ensure that the system is actually installed and used.
• It must be recognized that it can take at least six months of EPR/EHR usage before any
decisions about the success of the technology introduction (particularly in terms of individual
worker productivity) can be made.
• "Buy-in" of the organization is important. All users must clearly see the need for the change
if they are to support it.
Put another way, is f (D, V, S) > R? This is an expression of Gliecher’s “Change Equation”. It says:
“In order for change to occur successfully, the combination of Dissatisfaction with the
present situation, a Vision of a more desirable future, and the knowledge of the first Steps to
take in moving towards that future, must be greater than the Resistance to, or costs of, the
change. If any of the first three factors are missing, then change will not take place
successfully, no matter how strong the other factors are.”
The EHR journey is taking the NHS through terrain more complex than expected. The EHR
landscape is more like the mountains of Afghanistan than it is the deserts of Kuwait. One cannot
readily see the best route to follow – even from up high.
Having been a keen observer of the NHS information agenda for the past ten years, considerable
strides have been made in developing concepts and action around infrastructure; the applications
attached to the infrastructure will soon bear a significant amount of fruit. IfH is at an important cross
roads. Noteworthy breakthroughs are just around the corner.
The challenge for the future NHS is to translate an increasingly greater knowledge of the relationship
between social, clinical and technical issues into effective patient-centered systems that operate across
transient organisational boundaries. This is the bad news – it is not an easy task. It is somewhat akin
to asking the horse and buggy drivers of years gone past whether they could foresee the need for
windshield wipers on the first motorised vehicles. It was only when they began to operate these new
vehicles in the rain did they become aware that they could do with wiping the rain off the windshield.
Similarly, it takes time to gain knowledge of an EHR. Electronic records cannot be rushed and an
overnight courier cannot deliver them.
The good news is that there is strong and determined political commitment to reform the NHS and to
use information technology as a vehicle on which such reform will ride. If the Service and its
clinicians are equally committed, then watch out - the EHR journey will shift into high gear.

2. BACKGROUND
2.1 Introduction
In the spring of 2001, I was invited by the heads of the Information Policy Unit (IPU) of the
Department of Health and the NHS Information Authority (NHSIA) to comment on the state of
progress of Information for Health (IfH) including the implications of the emerging changes within
the English health care system. It was agreed that I would devote 1/3 of my time to the IPU (Appendix
A) and 2/3 of my time to the NHSIA (Appendix B).
During the period of 6th August – 19th October 2001, I met with over 50 individuals on one or more
occasions (Appendix C). I also read several documents as well as numerous e-mails and letters
(Appendix D).
My IPU work was to be guided by the statement from Building the Information Core: “In June 2001
the work of the demonstrator sites will be assessed with a view to making policy statements by
September 2001 in areas such as the development of the 24 hour emergency EHR, standards for
primary/community EPRs etc.”. The primary source of materials for the review was to be the ERDIP
demonstrator site reports on the NHSIA web site. It was decided that I would not visit any ERDIP
sites as I did last year. I was advised to take it as a given that the primary priority in terms of the
‘emergency EHR’ is the tool to assist in the day-to-day delivery of care as opposed to providing the
data to support clinical governance, epidemiology and retrospective analysis.
The following statements from the Secretary of State were to be kept in mind during the review for
the IPU:
“The EHR will hold summarised key data about patients, such as name, address, NHS
number, registered GP and contact details, previous treatments, ongoing conditions, current
medication, allergies and the date of any next appointments. The EHR will be securely
protected, created with patient consent, with individual changes made only by authorised
staff”.
“Over the next four years, every adult will be able to access their own at-a-glance
`electronic health record’.”
“The Electronic Health Record will help put patients in control. The sustained investment we are
making in NHS IT will help redesign the health service around the needs of its patients. In future,
every patient will have easier access to their own health records”.
The NHSIA remit was to focus on the state of ‘primary care’ services and its information needs with a
focus on the innovation in health services, patient-centered approaches, patient involvement, and the
development of patient-based records and patient access to those records. In addition, it was to
examine NHS Direct and how the NHSIA can better integrate with that development.
Working on the NHS information agenda, as I have for the past four years, continues to be both
exciting and gratifying for there are many valuable lessons to be shared with the international
community. The NHS has for the past ten years been seen by many as the leader in the application of
Information Management and Technology (IM&T) at a national level. Few countries have made the
policy and financial commitments that the UK has in recent years.

2.2 Acknowledgements and Apologies
Credit for any valuable ideas in this report should go to those whom I interviewed and to those
who wrote the excellent reports, letters and e-mails that I was made privy to. I am deeply
grateful to all of them. Without their candor and insights, my modest efforts would be academic
to the extreme.
I regret that in keeping with my promise to not name names, I am unable to publicly
acknowledge a number of people who I think are ‘right on’ in terms of the course of direction
and what should be done.
I accept full responsibility for any and all errors of omission and commission and for any
thinking, which some may consider to be too radical and/or not politically acceptable. I
appreciate that many of the Ministerial commitments have to be taken as ‘givens’. However if a
train is headed down a track where a bridge in the distance may collapse, it is surely to
everyone’s benefit to be forewarned.
I apologise if the report does not answer everyone’s questions. The further I delved into past and
recent developments, the more convinced I became that certain specific actions should be
undertaken. Hence my modest recommendations which attempt to find a balance between the
political imperative to ‘get on with it’ while retaining the spirit and intent of the original
Information for Health objectives.
In sincerely trying to tell it as I see it, I am acutely aware that others may view it differently. In
this type of work, one is constantly reminded of Disraeli’s remark, "It is easy to be critical but
difficult to be correct".

3. ENVIRONMENTAL SCAN
3.1 Government Policies and Direction

It would be an understatement to assert that the NHS is in the midst of a significant period of
transition. It is evident, even to an outsider, that the United Kingdom has a Government which
believes that the NHS had to be re-organised and made to be more equitable, accountable, and
customer-focused. One senses that it is a Government that is looking for obvious progress in
reforming the public sector - spurned on in part by negative media coverage about the NHS. The
Government expresses a desire to devolve power and decision making down to the frontline, to
decentralise, to provide patients with choice, to give local staff the resources and the freedoms to
innovate, develop and improve local services.
The Government’s vision has been clearly documented in a number of key policy documents,
legislative acts, and specific actions. Most notable among these have been:
• Department of Health reorganisation, including the integration of the Modernisation Agency

• Development of National Service Frameworks
• E-Government Strategy
• NHS Plan
• Shifting the Balance of Power in the NHS (StBOP)
The political expectations seem to be quite clear:
• Accountability - hence the high number of performance management targets, and the role of
the Commission for Health Improvement (CHI)
• Evidence of best practice leading to change in the way care is provided and delivered
• Empowerment of the patient and NHS staff including patient access to their own records
• Integration in terms of partnerships and a joined up Service - including social care
• Privacy to extend to patients consenting to who may access and use their data
• Quality of care to be consistent across the entire country - the Campbell article in a recent
issue of the British Medical Journal is the latest set of findings to confirm that English general
practice varies widely in quality of care
• Value for money - what works best at the least cost
• Web-enabled information technology as a key delivery tool to facilitate the provision of
seamless care
As a result of the perceived need to remove levels of bureaucracy, the publication of Shifting the
Balance of Power gives rise to 28 new Strategic Health Authorities which will replace the existing
Health Authorities, while the 8 Regional Offices of the Department of Health are to be replaced by 4
new Regional Directors of Health and Social Care - all this in an attempt to refocus the NHS around
the patient by moving decision-making down to the coal face. One does however, speculate whether
the new structures being put in place to manage the NHS will necessarily meet the needs of the
emerging clinical care networks.
Another noticeable change is that as a result of the recent reforms, there are now more gateways for
patients to access the NHS healthcare system. The traditional role of the GP as gatekeeper remains,
although other practice-based healthcare professionals are increasingly able to refer patients on for

other services, as are care professionals working in community settings. There are new methods of
access that have developed rapidly over the last few years. The development of call centre services
such as NHS Direct and Care Direct, of walk-in centres, of new ambulance and paramedic services
and the new roles for pharmacists as well as the development of A&E services, all enable the patient
to enter onto a pathway of care through a range of gateways. Eventually, an integrated care pathway
will be needed to identify locally agreed multi-disciplinary practice, based on guidelines & evidence
where available.
Change also manifests itself in the Audit Commission advice to local authorities, which are to have an
expanded role in overseeing local health services. Their expanded scrutiny role will be to play a key
role in improving local health, and health services, provided that realistic aims and clear ground rules
are agreed. The new overview and scrutiny committees will look at issues of local health, such as
public health concerns or accessibility to health care. The Commission’s report warned that the
expanded role represents a difficult challenge for local authorities - the committee members will need
to gain new skills and need to receive a basic grounding in how the NHS works.
Change continues unabated. A very recent announcement indicated that the work of the 300-400
Primary Care Trusts (PCT) is to be co-ordinated by new PCT ‘federations’ which are to be based
around the new strategic health authorities. They will not be formal NHS structures – but they are
expected to co-ordinate functions such as specialist commissioning. The way they work is to be
determined by the PCTs themselves – yet another manifestation of ‘empowerment’ by letting local
communities decide for themselves.
I commented last year that the NHS was in ‘initiative’ overload. This year, it would be safe to add
that the NHS is also in ‘target overload’. The number of targets and expectations on the Service
appear somewhat onerous. Targets abound everywhere be they the targets spelt out in the NHS Plan,
NHS Cancer Plan, the NSFs, Out of Hours Review, and the Local Implementation Strategies to name
a few. Rumors abound that there may be yet another set of new targets on the horizon.
3.2 Service Response and Reaction
One could not help but sense that many parts of the NHS are feeling beleaguered, micro-managed,
and suffering from “changeitis”. Many feel that they are constantly in response mode – particularly
to requests from the Centre, from Task Forces, etc. Most would not argue with the end points of
performance management targets, it is more about the number of them and the pace of change. Some
would argue that there is an inconsistency between the ‘empowerment’ rhetoric in StBOP and the
realities of performance management monitoring. One has to wonder how much energy will be going
into unproductive ‘gaming’?
This may be a somewhat harsh observation given most of the changes are quite new and still
evolving:
• The NHS Plan is only 15 months old

• NSFs are only about 1 year old
• Shifting the Balance Of Power is less than 3 months old
• The Department of Health re-organisation is only 2 months old
• It is expected that most of the PCTs will be formed by April 2002 – two years ahead of
schedule though it was not clear to me if they will be given funds immediately or later
• It seems inevitable that PCTs will merge further destabilising work flows and relationships

• The 28 new Strategic Health Authorities (StHA) are to become legal entities in the autumn of
2002 when the legislation is changed, though they will run as shadow StHAs for all intents
and purposes as of April 2002
• The existing 8 Regional Offices will disappear in April 2003, and the 4 new Regional
Directors of Health and Social Care will have different roles and responsibilities
There is some evidence that the workforce, particularly the GPs, is not in a buoyant move about all the
changes (West article). West argues that doctors' unhappiness is due to their feeling overworked and
under-supported. They hear the promises but then must explain to patients why the health service
cannot deliver what is promised. Endless initiatives are announced, but on the ground doctors find that
operating lists are cancelled, they cannot admit or discharge patients, and community services are
disappearing. They struggle to respond, but they feel as though they are battling the system rather than
being supported by it.
On another front, though most Chief Executives praised the Government’s plans for moving power
and responsibility closer to the front line of clinical care, 75% of them believed that the timescales and
rate of change promoted in StBOP would delay the delivery of the NHS Plan (Walshe article).
Concern has been expressed that most PCTs will likely be fully absorbed for 1-2 years with the
pragmatic realities of setting up a new organisation. The Walshe survey also revealed that most Chief
Executives fear that the PCTs may not have the managerial capacity and maturity to fulfill the
expectations on them. PCTs will also likely devote many of their early energies to their own
‘performance management targets’ and hence may have difficulty addressing what needs to be done if
the modernisation agenda is to be met.
The Government is placing an immense responsibility on PCTs by putting the majority of its NHS
purchasing funds in their hands. The argument for moving expenditure decisions as close as possible
to the cost drivers is sound but the jury will be out for some time on whether or not such immature
organisations will be up and running effectively in the time scales envisaged.
One does wonder if the PCTs will be able to fully absorb the complexity of secondary care and the
resource demands it will place on them. Concern has been expressed that the new StHAs will be too
far removed from the tensions that exist between PCTs and Trusts at a local level. As a result they
may find it difficult to effectively mediate the debates and disagreements that are bound to occur.
Some already view PCTs as being in a conflict of interest position when it comes to their providing
themselves with funds to deliver ‘their’ services.
When it comes to Information Management and Technology (IM&T), will the PCTs have the
experience and skills to negotiate effectively with suppliers? There are already accounts of some
PCTs making choices that are not consistent with the needs of the wider local health economy.
There is a sense amongst some in the NHS that, notwithstanding the intent to devolve authority, they
still feel a loss of freedom that is stifling creativity – even to the point of questioning their roles in the
new NHS. When the uncertainty about new PCT-based funding processes and the impact of the
development and implementation of clinical networks is taken into account it is difficult for some to
see the light at the end of the tunnel.
Any attempt to predict the full impact that all the changes and concerns is analogous to Bran Ferren’s
(Chief Imagineer for the Walt Disney Company) famous line: "Trying to assess the true importance

and function of the Internet now is like asking the Wright brothers at Kitty Hawk if they were aware of
the potential of frequent flyer programs”.
3.3 NHS Direct
That NHS Direct (NHSD) has the potential to become a truly integral part of the NHS is without
question – some would argue that it has already proven itself and can only get better. The increasing
number of phone calls being handled speaks for itself, as does the successful integration – in some of
the 22 sites – with Out of Office Hours services and GP cooperatives. One would have to say that the
Government got this one right, i.e. an evening, weekend and holiday service to assist British citizens
with any unplanned health ‘crisis’ that they encounter – even if there are still some GPs who remain to
be convinced that it will help them. Those NHSD sites closely integrated with local ambulance
services and A&E departments will continue to provide valuable lessons on what works best and what
pitfalls to avoid. NHSD provides a bona fide opportunity to realistically redesign the way care is
managed and delivered.
If the heart of the NHSD is its nurses and telephone receptionists, the nervous system of NHSD is an
algorithm-based decision support triage system designed to aid the assessment of undifferentiated
clinical symptoms (NHS CAS). The system aids the clinician to determine a safe level of care for the
patient. The system also supports the provision of self-care advice to callers. A face-to-face
application for the system is currently in the process of development. As well as redesigning the
presentation of NHS CAS to make it easier for clinicians to use, this work will also aim to link the
algorithmic content with care pathways for common presenting problems. This development may see
the system become a standard feature in ambulance services, A&E Departments, minor injury clinics,
OOH GP services (and some regular office hours services) as well as walk-in centres.
It cannot be anything but encouraging to hear of the ERDIP site that successfully completed the
enhancement of systems at GP practices and NHS Direct to permit the generation of a message, its
automatic transfer, and receipt. The messages successfully transferred were:
• From NHS Direct to practices: A call record detailing the content and outcome of a call to
NHS Direct
• From Practices to NHSD: “Blue forms” and alert to NHS Direct of patients with special
needs.
Appointment availability messages are next. Even without them, the pilot project to create two-way,
PKI secured, electronic links between NHSD and GPs desktops over NHSnet has to be deemed a
success. Excitement should be mounting in anticipation of the same functionality being made
available across the country.
NHSD has the potential to play a significant role in the emerging clinical care networks and in
particular the social care aspects of the integrated care pathways. One hopes that the NHSD sites are
working closely with their Care Direct counterparts and with Local Authorities in order to facilitate
this important aspect of the modernisation agenda – even if at the moment the use of NHSD is skewed
to younger people (often mothers of young children). As NHSD begins to work more closely with
PCTs and Care Trusts, the role of ‘case managers’ could take on a new meaning.
As good as NHSD is at the moment, it has already been recognised that there are a number of
improvements that need to be made – particularly if NHSD is to contribute significantly to the
emerging electronic health record. Some of these improvements are human resource issues (e.g.

expanding their workforce so that they can accept more calls – a concern to Trusts who are already
short of nurses), technical issues (e.g. merging their existing systems), marketing issues (escalating
the acceptance of NHSD amongst the GP community who have reservations about potential access to
‘their’ data), and organisational issues (rolling out the CAS decision support functionality so that it
can be used by others).
Other improvements that have already been identified and are more specific to the EHR include:
• Mapping to the National Strategic Tracing Service with the ability to access standard national
patient demographic data in order to realise the potential for NHSD to eventually contribute to
an EHR. This means collecting the NHS number on all calls where the callers are willing to
identify themselves - which in practice is the large majority. This will necessitate the British
public becoming much more familiar with their NHS number and why it is important that
they have it with them at all times.
• Dealing with the potentially political and complex issue of informed consent and verification
of caller identities. There is a difference in the processes of face-to-face care provision and
distance provision of care. In existing practices, records are held at the point of provision and
allow a traditional human verification of patient identity. GPs, as an example, rarely give out
information to inappropriate parties and their staffs understand their responsibilities. It has
even been said that husbands and wives are some times surprised at their strictness. If NHSD
staff are to access patients' records they will have to be able to verify the identity of the caller
and to leave an access audit trail for a Caldicott guardian or the patient to check.
• Numerous changes suggested by those at on the front lines have to be priorised – a process
which will consume the system supplier for sometime to come:
o Some of the algorithms still reflect the origins of CAS which was originally designed
to support nurses dealing with only HIV related calls
o Screen revisions – there is ‘noise’ on a number of them – i.e. they contain data
elements which are never used and/or utilize terminology which is still ‘American’
o The ‘call classification’ feature needs some work – ‘general’ is apparently chosen as a
default too often
o More sophisticated queue handling software (2/3 of the calls are placed in a queue)
o Pull down menus which have no logical order
o Lists are alphabetical (instead of most frequent on top) and not age-adjusted
o The system, at this point, is not quite ready for use in a face-to-face environment –
key data does not ‘jump out’ as it will need to if to be used by a wider audience
o The system is not as nurse friendly as it will likely be in future versions – e.g. the
Rationale section is a long block of text with no bullet statements which are easy to
see, there is no highlighting and no hyperlinks, etc.
o The system can handle multiple patient addresses but not multiple GPs
o Nurses are too often left on their own as there is no suitable algorithm for them to use
o Algorithms need to be modified so as to support a more directive approach in terms
of patient self management and empowerment
o Algorithms are binary (vs. Bayesian) and are based on determining what the caller
does NOT have - an approach which is conducive to supporting less skilled staff but
is less effective for experienced nurses
o Improvement in reporting capabilities is much needed

o As all input must currently be in uppercase, reports are generated which are below
modern output standards
o Development of a unified ‘back end’ is needed in order to interface with a variety of
OOH services systems
o Etc.
Critical to NHSD populating an EHR will be defining the clinical data (much of which will need to be
structured and hence coded), which will necessitate an exchange between NHS CAS and other
systems - in particular GP systems. There is experience from existing work on electronic records to
inform this. There is also the scope to refine this as a result of the work to integrate NHS Direct with
OOH services, in hour’s primary care services and ambulance services. One would also hope that
SNOMED CT would play an integral part in this development.

4. INFORMATION FOR HEALTH
4.1 Introduction
When it was announced in September 1998, the Information for Health (IfH) strategy was acclaimed,
both within the UK and abroad as visionary, appropriate and relevant to the needs of the NHS. It was
seen as a solid attempt to connect key national health policies with the capabilities of modern
information (computers and communications) technologies. It argued that the key to effectively
supporting clinicians in day-to-day care delivery was electronic records and that it was important to
recognise that little could be accomplished until the underlying information and communications
technology infrastructure was in place. It was a national strategy that was to be implemented locally –
an approach that was intended to foster a learning organisation by building the information capacity
locally where most information is processed and where the information must come from for all other
initiatives.
Most saw the strategy as an honest and pragmatic attempt to build upon the work of the early 1990s.
What few criticisms there were centered on the vaguely worded targets, an aggressive timetable, and
the challenges to be faced around "changing the culture". IfH garnered significant national attention
but early optimism turned to doubt that the aggressive objectives could not be attained due to existing
infrastructure, existing capabilities, procurement issues, as well as policy and culture changes.
By late 2000, in response to developments both internal and external to the NHS, an update to
Information for Health - Building the Information Core (BIC) – was issued which reflected the
changing NHS priorities as documented in the NHS Plan as well as the emerging e-government
strategy.
It is now almost 2002, and there is a growing recognition that a further update is needed - an update
which more directly takes into account the wide range of new organisations/programs and business
initiatives which have, in varying degrees, significant implications on the IfH agenda. A few of these
include:
Care Direct National Service Frameworks (NSF)

Care Trusts NHS Cancer Plan
Clinical Care Networks NHS Direct and NHS Direct On-line
Clinical Governance Out of Hours services and walk-in centers
Commission for Health Improvement Primary Care Trusts
Integrated Care Pathways Public Health Observatories
Modernisation Agency Waiting List Project
National Institute for Clinical Excellence Winter Emergency Strategic Team (WEST)
National Patient Access Team
As stated in ‘Information Implications of Shifting the Balance of Power’, the Government’s intent is
to devolve power for managing the NHS to local level, in favor of patients and front-line staff. This
represents a significant change programme for the NHS with the creation of Strategic Health
Authorities and the devolution of operational responsibilities to Primary Care Trusts. It is already
recognised that the boundaries of Primary Care Trusts (and Care Trusts) may be subject to change in
the future as issues of clinical need and local circumstances become clearer. For this reason, it is
important to ensure that any information system is able to cope flexibly with future changes.

The Government’s aim is to deliver a national health service that improves equity of access, and
ensures that a consistently high quality of service is provided to patients and to the public. The
achievement of the Government's targets for the NHS will rely on the provision of efficient and
effective information systems to enable the benefits for patients and the public to be achieved. The
Government’s drive to modernise services, as part of its e-Government agenda, has placed new
demands on public sector organisations. For the NHS, the goal of achieving widespread availability of
reliable and accurate electronic patient records will require on-line, real-time access to reliable and
accurate tracing services.
The modernisation objectives set out in the NHS Plan and in the NSFs for key clinical areas - CHD,
Cancer, Mental Health, Diabetes, Care of the Elderly - state explicitly the need for clinical pathways
and patient journeys to be supported by electronic clinical records. The crucial role for IfH in
underpinning the NHS modernisation needs to be recognised more explicitly and be reflected in a
more 'joined up' performance management of the NHS.
As I commented earlier about the Service’s reactions to the Government’s direction, so too is there a
reaction in the information community. Given that there is a definite drive towards devolution of
responsibility through StBOP, how can IfH and BIC square up with this transference? Even if effort
was spent attempting to make all the links, is there the capacity to join all this up? In the last two
years, it has proven very difficult to effectively align the IPU and Primary Care Branch information-
related initiatives - let alone the NHS Direct work - with the wider IM&T agenda.
4.2 Political Expectations and Pressures
The Government’s expectations are perhaps best exemplified by the many quotes about the impact
that IT will have on health care delivery. The most famous quote goes back to Prime Minister Tony
Blair’s 1998 speech to the NHS 50th conference where he set the tone of things to come when he said
“If I live in Bradford and fall ill in Birmingham then I want the doctor treating me to have access to
the information he needs to treat me.”
Since then, the number of statements expressing political expectations has increased, a few of the
more recent ones being:
• “If an EHR is needed in 2003, then we would have to have a national solution,
delivered over a national infrastructure, that was focused on a very limited range of
data that is needed for basic care in emergencies.”
• “By 2003, we must focus on ensuring we have an NHS that enables all staff to have
reasonable access to e-mail and web browsing, and able to send clinical information
securely.”
• "Electronic systems will start to replace paper over the next five years. This means
that by logging on to a computer, medical records will be available to both patients
and doctors. Test results, repeat prescriptions and appointments will be organised via
e-mail, saving time and worry by cutting days off the time it currently takes to handle
these communications.”
There is a clear sense of urgency in the air; it is palpable. It consumes most discussions - little time is
spent reflecting on the achievements and learning of what has worked and what has not worked in the
past three years.

What seems to be ignored, or at least overlooked, is that much of IfH is about infrastructure – the
basic underlying and linking framework that provides shared resources for healthcare providers and
patients enabling information to flow in an appropriately structured, identifiable, unambiguous and
secure way. As pointed out in the NHS Infrastructure Service Strategic Outline Case, the NHS has
historically adopted a piecemeal approach to the procurement and implementation of infrastructure
services. While progress has been made in individual areas, the lack of commonality has led to delays
and barriers to communication due to incompatibility between systems. Two particular issues are the
difficulties of deploying new technologies and the difficulties of managing common levels of
attainment across the NHS.
Infrastructure breeds impatience. It is important to note that the provision of infrastructure services is
an enabling mechanism. The infrastructure itself will deliver some benefits, but the main outcomes
will be achieved by the provision of additional applications and services. As with any infrastructure,
Information Technology (IT) infrastructure does not provide direct business performance; it enables
other systems that do yield business benefits. IT infrastructure is strikingly similar to other public
infrastructures such as roads, hospitals, sewers, schools, etc. They are all long-term and require large
investments. They enable business activity by users that would otherwise not be economically
feasible. They are difficult to cost-justify in advance as well as to show benefits in hindsight. They
require a delicate investment balance - too little investment leads to duplication, incompatibility, and
sub-optimal use, while too much discourages user investment and involvement and may result in
unused capacity.
4.3 Accomplishments
It is important to acknowledge that much has been achieved since IfH was announced three years ago.
It is easy to forget that two new organisations were created as a result of the IfH, namely the IPU and
the NHSIA. The NHSIA is a large organisation that was formed by bringing together 20+ units, many
of which had operated more or less independently for years. Merging them into one corporate entity
was a non-trivial task.
The NHSIA should be proud of the good it has accomplished, both in terms of its organisational
structure and its part in developing the infrastructure critical to IfH’s success. Some, myself included,
will argue that more should have been done in the past two years. However, focusing on only the
negative ignores the positive and there are many positives. Everyone involved, from the Department
of Health and the IPU, through to the NHSIA and those operating at the cold face should be pleased
with what has been accomplished to-date.
Particular pride should be taken vis-à-vis the use of computer technology in GP practices - even if the
critics will argue that more should have been achieved by now. According to the 1 October 2001
issue of Harris Interactive Health Care newsletter, 59 percent of primary care physicians in the United
Kingdom, and 52 percent of those in New Zealand, use an electronic patient record (EPR) while a
mere 17 percent of U.S. primary care physicians claim to do so. An impressive 87 percent of U.K.
physicians claim to use electronic prescribing as compared to a lackluster 9 percent of U.S.
physicians. Harris' estimates regarding the penetration of the EPR among U.S. physicians may
actually be somewhat high, and include physicians who use computers to keep records in ways that
are not really an EPR. If the transcriptionist types the chart notes in Microsoft Word, and saves the
files, many doctors would answer yes to the question.

What the Harris report does not acknowledge is that there are a number of British GP practices that
are already virtually paperless. Even better, the clinical data in their computer systems is using a
common coding system (READ) – a tremendous advantage to the clinical audit and clinical
governance aspects of the modernisation agenda.
It is the envy of many countries that by 13 September 2001, England had:
• 8469 (97%) practices with an NHSnet line installed

• 8621 (98%) practices with an Acceptable Use Policy signed, which represents practices
committed to the NHSnet security policy and therefore committed to joining the network
• 8095 (92%) practices with an e-mail system installed
Critics will point to the current lack of applications available and that all of the above is window
dressing. Others would argue that if the above infrastructure were not in place, all the applications in
the world would do little to facilitate electronic communications within the NHS.
The central funding of the connection of GP systems to NHSnet has been a great success. The NHS is
the undisputed international leader when it comes to the application of information technology in
primary care. Partial funding of GP systems may be seen as a problem in the UK – it is but a faint
hope in the rest of the world where GPs are on their own when it comes to funding IT in their
practices. There is validity in the argument that so much more should have been accomplished over
the past number of years – e.g. being able to easily transfer records electronically between practices.
However, everything in life is relative and compared to most countries, the UK is still ahead of the
game.
It would have been first-rate if the same financial commitment had been made in areas such as
Community/Mental Health, which accounts for a third of the NHS business. However the UK can
take some solace in the fact that very few, if any countries of the world, have historically invested in
these sectors.
Moving back to accomplishments, even the harshest critics would have to be pleased with other key
pieces of infrastructure that are either in place or close to being delivered, a few being:
• The Local Implementation Strategy (LIS) process – a mechanism to bring together

organisations in a local health economy and a great success in many parts of the country

• A more reliable and robust NHSnet

o My 1999 review commented that this was perhaps the greatest risks facing IfH at that
time – a risk which has since been greatly diminished
o Though improvements have been made, there is still concern that it is not always on,
and it is still not quick and unfailing enough to support the type of activities that the
EHR will demand
o An increasingly wide range of users will require access to the network (section 3.4.3
of the NHS Infrastructure Services SOC)
o Without a rock solid NHSnet, little else that is national in nature matters, no matter
how good it is.
• A national NHS Number – perhaps the most critical item needed on the EHR journey
• Open Exeter and NSTS - the foundations of an enterprise-wide (in this case the whole
country) master patient index - oh how Canada would dearly love to have one
• Over 300,000 health care professionals in the national e-mail directory
• The decision to fund all NHSnet messages centrally
• The Requirements for Accreditation (RFA) for GP Computer Systems – warts and all – it has
facilitated constructive convergence and is a standards setting process that most countries do
not have
• Changes to GP terms and conditions permitting the use of electronic records and removing the
legal requirement to keep paper records
• The ERDIP program – a concrete commitment towards the research and development of the
EHR
• Pathology Messaging – even if it has been scheduled for a number of years, it is a capability
that a number of countries are pursuing as a priority. Few, however, will be able to say that
they have 60% capability by March 2002, let alone 100% by December 2002
• The national roll out of ICD-10
• The collaborative work with the College of American Pathologists to replace the Clinical
Terms Version 3 (Read Codes) with the new SNOMED CT thesaurus. The Read codes are
still the jewel in the IfH crown - even if some would argue they are tarnished by a lack of
central commitment, an appreciation of their role in the EPR/EHR journey, and the
uncertainty of the SMOMED CT implementation costs
• The Knowledge Management efforts underway in the National Electronic Library for Health,
NHS Direct On-line, nhs.uk and PRODIGY.
The NHS has already garnered unique insights into policy, privacy, patient involvement, working
together, and key “cultural” issues. They are testing many possible approaches before “betting the
farm”. The turbulence caused by the intensity of change within the NHS and internally within the
NHSIA, can easily cloud achievements and obscure the progress towards delivery of the information
infrastructure needed for a modern health service.
Having been a keen observer of the NHS information agenda for the past ten years, big strides have
been made in developing concepts and action around infrastructure and it will soon bear a significant
amount of fruit. The IfH implementation is at an important cross roads; more noteworthy
breakthroughs are just around the corner.

4.4 General Observations
The following are observations garnered from many conversations and the documents reviewed.
They are not in any order of priority.
1. Am I wrong? Has there been a shift from IfH’s primary intent to supporting day-to-day clinical
practice to one of collecting data for retrospective analysis (e.g. clinical governance)? IfH’s
original intent was akin to providing parents and their children with the means to make their lives
more productive and satisfying. The apparent shift in priorities seems aimed at providing friends,
counselors, and government agencies with information that they can use to help parents and
children understand their state of affairs and behaviors. Put another way, the original intent of
IfH was akin to aiding pilots and passengers while the retrospective analysis approach is aimed at
assisting airline analysts and regulatory agencies. Both sets of communities have important
needs; the challenge is deciding which ones to concentrate on given the political realities of the
day.
The current state of affairs has a comparable, and uncomfortable, feel to when the 1992 IM&T
agenda was ‘hijacked’ by a political imperative to move to an internal market and establish
systems that would manage the competition and contracts exemplar.
Notwithstanding the potentially uncoordinated creation of new clinical datasets to satisfy NSF
requirements for Cancer, CHD, Diabetes, Older people, and Mental Health, many of the existing
datasets are administratively rather than clinically focused and likely founded on outmoded
models of care that are constrained by organisational boundaries. Counting is currently vertical
(functions such as inpatient care); in the future counting will have to be horizontal (pathways) and
it is going to be significantly more complex. If everyone is not careful, there are going to be
many ad-hoc data collection systems built or installed simply to satisfy the NSFs. Creating
information systems to capture clinical data sets are an interim solution – they would not be
needed if EPRs and the EHR were in place.
Is the NHS headed for another Körner-like data collection period? The answer will unfortunately
be ‘yes’ if there is no regular and meaningful feedback to those collecting the data. If one of the
intents of the datasets is to facilitate information sharing across pathways it will be critically
important to set up effective information exchange methods – they may in some ways be even
more important than the data itself.
It might be worth remembering that Dame Körner’s guiding principle was that all data should be
derived from the operational requirement of delivering front-line health care. It is equally
relevant today - the clinical governance agenda will only work if the principle of data for
operational requirements is maintained. Anything else quickly becomes meaningless to the front-
line; they will to run two different systems, one for reporting up the line and one for dealing with
patients.
2. I detected an increasing awareness that a number of the IfH targets are: a) unachievable and b) not
closely enough linked to the targets associated with business-related activities such as the
implementation of NSFs, the Cancer Plan, etc. Two recent Strategic Outline Cases, those for
Populations Records and Electronic Bookings, provide excellent assessments of the current state
of affairs, the case for change, the important business needs, and the barriers that will need to be
removed if IfH is to reach its full potential.

On the famous EPR level 3 targets, I was unable to find anyone who could give me a definitive
answer as to what percentage of the NHS Trusts were there yet.
3. There are 40+ EHR-related projects functioning at national level (Appendix E). There are also a
number of ‘non-health’ initiatives that are very relevant to the EHR journey, namely:
a. Civil Registration
b. e-Government information framework (e-Gif)
c. Information for Social Care Strategy
d. Local Authority (Social Services) based Local Information Plans (LIP) - surely a key
element of the EHR given the clear policy of integrated care with a single common
assessment process
What is particularly concerning is the wide range of people from a wide range of organisations
leading all of these initiatives. How aware are they of each other’s efforts? It is not clear who is
bringing it all together. How do all these initiatives join up? Does the ‘big picture’ exist – if so,
it should be brought out and passed on to the Service?
4. There are tensions in the field. Those attempting to implement EPRs feel that emphasis is all on
primary care and the EHR. At the same time, some of the primary care and community groups
within the LIS communities feel that most of the IM&T resources keep going into acute care. Is
it a valid observation that the NHSIA seems to be devoting very little of its resources to the EPR
(vs. the EHR) agenda?
Some are arguing that the approach to implementing EPR systems in the NHS may be too
fragmented with each Trust or local NHS community deciding its own approach. They would
like to see more thought being given to acting more like one NHS with a more standardised
approach to developing and procuring core IM&T systems. This could take the form of
determining common standards and specifications and conducting collaborative procurements on
a national and/or regional basis. This type of approach appears to have worked well with the roll
out of ICD-10, NHS Direct and the recent Microsoft office systems software procurement. The
South Western collaborative EPR procurement is often cited as another good example though I
understand that the jury is still out on that one.
Some have argued that this suggested approach is one that many large private sector companies,
such as the major retailers, have adopted for their core systems. They point out that Tesco does
not allow individual stores to develop their own Electronic Point of Sales systems – however
unlike hospitals, one Tesco is much like any other Tesco except in location and products lines
stocked. If only health care were so simple and relatively uncomplicated.
On the other hand if the intent of government is not of a Tesco's but more of a Spar or McDonalds
franchise operation where individuals have degrees of freedom within a set of franchise standards,
then will the mandate be to set standards, and set up arrangements to help the franchise operators
get good value for money in purchasing their raw goods, but not tell them how to make or sell
their products?
5. Where is the organisational learning that is so critical to long-term success? I found little
evidence of anyone bringing together the many lessons being learnt – even if it was one of the
original intentions of ERDIP. I believe that the original intent was one of ensuring that the whole
NHS was engaged in the ERDIP work so that those sites not selected, as demonstrators did not

feel disengaged from the small number of sites who were. The ERDIP program is better than it
was last year in terms of making reports available on the NHSIA web site but much more needs to
be done. Publishing reports is only a small part of learning.
The lack of learning is particularly apparent in terms of the lessons from outside of the ERDIP
sites. One only sporadically reads or hears of good work being carried out in places such as South
Humber, Herefordshire, or Kensington, Chelsea and Westminster, to name a few. What about the
lessons being learnt in Scotland such as the web-based EHRs in Inverness and Dundee or the
Tayside Diabetic Programme?
6. Is the LIS process at risk of disappearing? It has facilitated local health economies (LHE)
working together across sector and professional boundaries. IfH is supposed to be all about LHEs
working it out together locally, is it not?
Undoubtedly, the strong local health economies will stay together. Their targets are already likely
aligned to business need (NSFs, etc.). They will also be the ones to successfully integrate their
LIS and LIP. The shaky LHEs may stay together but what will the incentives be for PCTs to
work collaboratively? It would be a loss if the weak LHEs dissolved but they most likely will.
One anecdote was recounted that a local health economy with 5 PCTs agree on one thing – how
much they distrust each other.
There are emerging requirements for PCTs to develop and support population health requirements
as well as service delivery. These requirements necessitate improved access to comprehensive
and accurate patient demographic and clinical history databases to support analyses that include:
demographic profiling; morbidity assessment; epidemiological analysis; service monitoring and
planning; and distribution and optimisation of resources across communities. How many PCTs
have a common agenda with their neighboring PCTs? Will the new StHAs be inclined to and be
able to keep the LHEs together?
Who will provide the IM&T leadership? If the IM&T portfolio is given to different people within
each StHA, how much consistency can be expected across the country? Will IM&T funds be
ring fenced at the StHA level? If not, will PCTs be inclined to divert IM&T funds to other non-
IM&T areas such as over expenditures in prescribing medications? Will their IM&T priorities be
disproportionately weighted to primary care?
Will the PCTs decide to express their new freedoms and each do something totally different?
Will local innovation be guided by strong enforcement of common standards? Will Trusts have to
expend undue energies seeking IM&T funding from their host PCTs?
Will we see the formation of ‘information networks’ along the lines of the clinical networks? If
so, who will be the equivalent of the clinical leads so vital to a successful clinical care network?
Who will take over the important facilitation role played by the Regions; they currently hold the
ring and co-ordinate activity across LIS communities? Is this to be lost until the new PCTs and
StHAs are sufficiently mature "to pick up the baton"? Will the Regional Heads of Information be
motivated to facilitate the important short-term role of managing the transition to the new model
thereby ensuring that the good bits of LISs are migrated and the whole picture fits together?
So many questions, so few answers.

9. It was most disconcerting to learn that 70% of the hypothecated funds intended for investment in
IM&T in the 2001/2 national allocations were diverted to other purposes. If this problem persists
in 2002/3 the NHS will fail to deliver key IfH objectives, particularly the development of
electronic records, and this will undermine the clinical modernisation agenda in the NHS Plan. If
it happens again, Information for Health will be irrelevant.
The problem with what funding there has been is that it has been prey to more immediate targets
in IM&T and beyond. Once into the electronic record territory, a longer-term investment
approach to guarantee blocks of funding for both development and implementation over several
years as well as the on-going revenue costs is going to be needed.
10. None of the current population record systems provide the functionality required to achieve the
strategic objectives and the duplication in them results in increased cost and complexity. It is
estimated that there are currently some 250 disease registers. Most of these have been developed
independently to meet specific requirements of a particular community of interest, and contain
data that is defined in many different ways. This piecemeal approach compromises the ability of
health planners to do their work, and can potentially expose identifiable patient data unnecessarily
through the failure to implement appropriate confidentiality protocols.
11. Progress was noted in terms of the national e-mail project known as Project Connect. Almost
300,000 NHS clinicians now have a unique e-mail id - based on the SMTP addressing protocol -
in order to facilitate simple, but important, communication amongst themselves. However, all is
not perfect.
For some reasons the GPs were not given ‘standard’ e-mail ids (i.e. first name.last name@….).
Instead they were given meaningless ids related to their practice code numbers. As a result, many
GPs do not use their NHS id, preferring instead to use their private Internet Service Provider ids.
It is not only the naming which is a problem. Many GPs wish to access their e-mail from home
(or other sites) and are not able to develop an NHSnet connection from outside their offices.
They also find NHSnet is still not dependable enough and is still too slow in comparison to other
Internet providers. Some GPs would also prefer to work outside of NHSnet for patients' needs
rather than inside it, a serious condition that should be investigated quickly. Some GPs have said
that 1-2 years ago, they did not think that NHSnet would produce a solution that would serve both
the patient and public interest. Hopefully most of them feel less pessimistic now.
12. Even if the IM&T is accepted as one of the main underpinning platforms for a modernised NHS, I
fear that the information agenda is at risk of being diverted by the performance management
agenda as a result of:
• The emphasis on star ratings

• NHS Plan targets (though these include IM&T targets, I would suggest that they are seen to
be less important to most Chief Executives)
• NSF targets
• Cancer Plan targets
• Commission for Health Improvement (CHI) activities
• Other “My job as Chief Executive is on the line” targets

4.5 ERDIP Lessons Learnt To Date
As of September 15, 2001, of the 82 reports written since November 2000 (documents which are post-
PID and project briefs), only 17 contain the type of information that could be used to recommend a
course of direction to follow (Appendix F). There was speculation that some sites had produced
reports, which were not on the NHSIA web site – these were obviously not reviewed.
Most of the reports on the NHSIA web site are simply:
• Descriptions/plans of what is intended to be done or evaluated

• Patient questionnaires
• PowerPoint presentations
• Requirements and/or technical specifications (useful in terms of identifying the complexities)
• Status reports with little or no discussion of findings, issues, or lessons learnt
Given that most of the sites are only one year into their experiments, it is not surprising that less than
one in four of the reports provide the type of information from which a clear direction of travel can be
defined. Is it valid to infer that some of the reports were generated simply to put something on paper
in order that funding would continue to flow?
Notwithstanding this, there are none-the-less a few excellent and informative reports, namely:
• Bradford’s emergency EHR progress report

• Cornwall’s creating a single population index
• Durham’s ethical framework for the EHR
• North and Mid Hampshire’s summary of data, technical, and information sharing standards
• South Staffordshire’s data capture issues and information standards implications
• Suffolk’s general protocol for sharing information between health and social services
• Walsall’s enterprise Master Patient Index statement of need
A few other reports also provide excellent insights into the complexity of the EHR journey. The EPR
and EHR are not the electronic form of the old paper record; they are something entirely different and
surprisingly more intelligent than what people imagine. The real EPR and EHR will be the
convergence of the data that is stored with the intelligence that has been codified. It will be used to
assist clinicians in the difficult task of diagnosing and prescribing for patients who have increasingly
complicated diseases or a constellation of diseases.
Appendix G summarises a few key selections from the 17 ERDIP reports. They provide the signposts
as to where standards work is still needed. They identify a need to do a gap analysis to illustrate
missing standards for NSF support, EHR headings, alerts and allergies, primary care summaries,
personal health records, and EPR to EHR information transfer. They also suggest that there is a need
to agree a procurement approach for the EHR with suppliers, including the role of standards. They
further recommend that there is a need to agree, mandate, test and implement these standards by 2005
- across a wide variety of NHS suppliers. An understanding of the EHR in terms of user requirements
and options is emerging from ERDIP. More learning needs to be expedited in the areas such as
disease registers, access by wider social care, and personal health records.
The standards-related issues in Appendix G are but a subset of many yet to be resolved EHR issues.
They do not include matters such as clinical consensus, clinical ownership (buy-in), change

management (including willingness to share data), password control, procurement, resourcing, size of
workstation monitors, training, etc. Undoubtedly all of the ERDIP sites will come up with similar and
additional findings when they produce their final reports in the summer/fall of 2002. It should be
noted that 44% of the 383 products in the ‘ERDIP Joined Up Deliverables Master List’ have target
dates after September 2001.
The IPU asked me to find out “how many ERDIP sites are not making progress due to the lack of
standards”? This was a difficult question to answer given that the majority of the reports on the
NHSIA web site provide little evidence on which to support an informed conclusion.
Based on the material available on the NHSIA web site, I believe that it will not be due to the lack of
national standards that some sites may not achieve the key deliverables outlined in their project briefs.
The succinct reports being submitted to the ERDIP Project Board reveal that it is other issues (i.e.
unrelated to standards) that are the cause of slippage, namely: meager change management, deficient
system supplier co-operation, lack of clinician commitment and buy-in, lack of resourcing, etc.
Based on the ERDIP work to date, I am of the opinion that it is still too early to determine which
model along the EHR continuum will be most suitable at a national level:
Virtual EHR à Events EHR à Big Box EHR
Each model has its pros and cons. The Virtual EHR contains only pointers and is based on a scheme
of viewing patient data where it is located only when it is needed using Internet–based networks and
web browsers. The Events EHR (which could also be referred to as the HITS EHR in that it records
where and when the patient ‘hits’ the system) is the overview/summary type of EHR. If pointers were
added to it, users would then have access to more detail if needed. The Big Box EHR, where
everyone uses one Clinical Data Repository provides all clinicians with the data granularity which
some argue they require, is an approach that might be both feasible and workable in some LHEs.
Although more complex conceptually, it may be more realistic to accept that the EHR must be a
combination of approaches using standard data and messaging protocols. Some will argue that
browsing of the results is fine and gives the GPs all the information they need. Others will have the
view that unless the results are fully integrated into their local GP clinical system they cannot have the
view of the patient record they need when making clinical decisions.
From the limited material available up to now, it is clear that there is still uncertainty about the EHR,
not only from a standards perspective but also in terms of its content, functionality, protection, and
usage. Whether the EHR should be a primary and/or a secondary record, and whether it should be an
active (directive) or passive (retrospective) record also needs further investigation. If active, then the
full array of decision support tools (alerts, reminders, etc.) would have to be included. That being
said, it could be argued that even if the final shape of the EHR is not known, there is perhaps enough
known to develop a first generation of it.
Some sites have already shown how difficult it is going to be to reach consensus amongst clinicians –
particularly when the terminology they use differs. These uncertainties make it all the more important
that the ERDIP program be fully evaluated as was intended when the programme was first
established. There is no such thing as a solution to a problem when the problem itself has not been
fully defined, still less agreed.

At the end of the day it is going to come down to the clinician asking (directly or via his/her support
staff) a number of unchanging questions:
• Who is this patient? Have I got the right one?

• Has s/he had any previous "history" that might give me some help with deciding what to do
next?
• What is the recorded wisdom about similar cases?
• How do I schedule something to happen?
• How do I consign my thoughts and actions for others and myself to use in the future?
The EHR journey is taking us through terrain more complex than expected. The EHR landscape is
more like the mountains of Afghanistan than it is the deserts of Kuwait. One cannot readily see the
best route to follow – even from up high.
4.6 ERDIP And The Consent Issue
The one standards-related area, which may be a very real obstruction to the sites achieving their key
deliverables, is the issue of informed patient consent and who has access to which portions of the
EHR. As stated in the Populations Records SOC, whilst there is huge potential to make better use of
personal data to deliver benefits to the public, this will only be realised if the public trusts the way in
which the public sector handles its personal information – which means meeting their rights and
legitimate expectations on the protection of personal privacy; and the data to deliver real benefits to
individuals. In particular, the commitment to informed consent as the norm for handling patient
information will call for action to be taken to address the current shortcomings in the ways in which
the NHS captures, stores and processes personally identifiable information.
As the final report from the Hadfield project concluded, patients ultimately would like all health
professionals to have access to the EHR if required. They want to see an integrated health service and
minimal repetition of information for both patient and health professional. Patients would like to be
able to appoint a custodian to access their EHR in the event that they are unable to do so. They also
desire the application of audit trails with in the record and want to be able to access these trails.
The Eversheds report warns that clarity is needed concerning who has what rights in respect of patient
records and how these rights interact. The issue needs to be resolved in order to establish who needs
to be involved in giving consent to transfer data into the EHR and its subsequent use. No one has yet
been able to satisfactorily resolve the issue of ownership. There is no legislative guidance on this and
apparently this issue has not been tested in court. If some professionals are reluctant for patients to be
informed of what data that they currently have access to, this raises an issue concerning the level of
control that patients have. The practice of avoiding these issues by keeping patients in the dark is not
one that can continue with the emergence of the EHR - especially in light of the BMA and RCGP
concerns and the legislation concerning data protection and human rights.
In Evershed’s opinion, a number of bodies are currently exposed to a degree of legal risk in relation to
patient records – an issue that should be addressed at the right level as soon as possible. Many of
these organisations may be unaware of their duties and obligations under the law in respect of patient
records. They may also not fully appreciate the implications of breaching them. It should not go
unnoticed that negligence claims against NHS hospitals in England have risen by £700 million in one
year, to an estimated £3.9 billion - almost 10% of the annual NHS budget 1999-2000 for England of
£40.1 billion (National Audit Office Handling Claims for Clinical Negligence May 2001).

The consent issue is multifarious. The following two, tongue in cheek, suggested consent statements
about the use of clinical decision support systems (an integral part of a true EPR and EHR) recently
appeared on a medical informatics Internet discussion group.
“WARNING: our physicians and nurses are attempting to use antiquated manual records
keeping systems and their own limited memories in an often futile attempt to deliver a
complex set of services without error. The logic of these human beings has been tested
incompletely at some point in the past, but we offer no warranty expressed or implied that
any individual decision made or action taken will be provably correct. Moreover, we do not
know the effect of ageing, distractions, overwork, and failure to communicate on the overall
care you will receive. Because we do not take a systems approach to health care services, by
signing this consent you agree to participate in this admittedly error prone and potentially
life threatening activity.”
OR
“In our effort to provide you with the best possible care, we frequently research the medical
literature, often consult with colleagues who may have more experience than we, and
regularly accept the advice of medical specialty societies. Moreover, we occasionally look
at medical records of patients who have had illnesses similar to yours. Please be advised
that the literature may be wrong; the experience of our colleagues may be biased; the
records may not be complete or accurate; and that specialty societies may have conflicts of
interest. It is our duty to inform you that the logic we employ has never been tested in
clinical trials. Incidentally, an increasing number of the resources we access may now
reside on computers.”
Along the same lines, the following serious observation was made:
“A Decision Support Systems (DSS) may look at a range of data from a patient's past in
order to make its recommendation. Some systems may even go out and gather data from
disparate systems (dynamically or by consulting a data repository built for this purpose). At
this level it seems like the patient's consent is to obtain permission to do this, i.e., go hunting
outside of the information collected for the present episode, but only with respect to this
patient.
The second issue is the use of the data from many patients to develop and perhaps test the
logic or behavior of a DSS. For example, systems like the LDS Hospital infection control
system rely on regression equations using data from a large population over a 5-year period
and a 6-month period. Ostensibly, this retrieval is without disclosure of identifying
information, since the process has been automated, but may still require consent. This is an
example of a system in operation. The lines may be still blurrier for a system presently
under development as the processes may not yet be automated. Further, since the
development of such systems is increasingly being done by entities that do not actually
provide the care (such as vendors), is consent required to release the data? Again, because
the data can be de-identified, the major concerns may be different than those associated with
first issue. However, it is my impression that a strict interpretation of subsequent
release of the data requires consent and I have not been able to get any compliance
officer to tell me how you write a consent form to cover the use of data, even if collected
as part of standard care for development of algorithms you haven't thought of yet.”

The commitment to informed consent as the norm for handling patient information requires action to
be taken to address the current shortcomings in the ways in which the NHS captures, stores and
processes personally identifiable information. In particular, it will be necessary to ensure that where
identifiable information is required that patients are properly informed of what data is being held, the
uses to which it will be put, and those who might have access to that data. Except in the case of
statutory requirements, patients would also have the right to refuse consent. In all other
circumstances, steps will need to be taken to anonymise the data.
I understand that there is work underway to determine which data flows can implied consent cover,
taking into account the views of key stakeholders and what information needs to be given to the data
subject for consent to be valid. The importance of that work cannot be stressed enough.
4.7 The 24-hour Emergency EHR
The IPU also asked “What policy statement can/should be made as to the development of the 24-hour
emergency EHR?” This was another difficult question to answer in a knowledgeable manner.
Although nine of the seventeen ERDIP sites have some facet of the ‘Emergency EHR’ in their
mandate, only 5 have documented their early findings.
A further complication is the wide range of views as to what is meant by the so-called ‘Emergency
EHR’. Much depends on how one defines ‘emergency’ which is really a spectrum of unplanned (or
unscheduled) need which runs from the worried well at one end to the nearly dead at the other.
Worried well à Non-urgent à Urgent à Emergent à Near Death (life threatening)
From a pragmatic perspective, the pressing business need for an EHR is on the left-hand side of the
spectrum, not the right (Figure 1). There are tens of thousands of events/interventions, which occur
daily on the left-hand to middle part of the spectrum; there are but a few hundred events/interventions
that occur daily on the right hand side. The small percentage of life-threatening cases (less than 10%
of all ambulance calls according to “Life in the Fast Lane”) require little historical data as clinicians
tend to act on what data is immediately available (vital signs, blood type, etc.) – referred to as ‘treat as
seen’ in the EHR Strategic Outline Case. What has however been documented to be useful in life
threatening cases is being informed of the patient’s allergies and current medications.
Volume of daily events
High
Low
Worried Well Near Death
Figure 1: The ‘Emergency’ Spectrum
Those at the peak of the curve in Figure 1 are for the most part the elderly who generate the majority
of unplanned care events – particularly the complex ones. It is in this arena that the greatest need

exists to have details about the patient and to know where s/he has been in the past (i.e. the recording
of events which some argue is one of the most important functions of the EHR) in order to direct the
patient to the most appropriate service. The prevalence of elderly patients also indicates the
importance of involving social care agencies, as they often have important parts to play in the delivery
of care services to such patients.
Significant changes in the way the NHS works will be required to achieve the full benefits of the
creation of an electronic environment for the NHS through the implementation of EHRs and EPRs
(regardless of which EHR model is adopted). To secure these changes, the immediate advantages to
clinicians - of improved access to patient data - will need to be greater than the perceived burden of
the changes themselves. Access to emergency care data will bring significant advantage to some –
but only a relatively small minority of clinicians and patients. There is a real danger that the relatively
limited advantages of the interim emergency care solution will be insufficient to drive the required
changes in NHS practice necessary to secure the full benefits of EHR implementation.
The pressure for immediate results can be distracting. The EHR is a journey of many little steps. The
greater the number of steps taken, the more likely it will be that the followers will seek reassurance
from their leaders that they should continue on with the trek.
Notwithstanding the above arguments, if the current government is both a) action-oriented – wanting
to see tangible returns on their information agenda investments and, b) wanting to see some form of
‘Emergency’ EHR - as a result of the famous Tony Blair quote - then what are the options available?
4.8 The EHR Strategic Outline Case
The EHR Strategic Outline Case (SOC) addresses some of the questions raised above. It is an
excellent document; particularly in terms of documenting the current ‘emergency’ care services and
identifying the investment objectives.
However, in my respectful opinion, the EHR SOC process was dangerously flawed – particularly
when compared to others such as the Electronic Bookings SOC. There are a number of reasons on
which I reluctantly base this view – fully appreciating that the state of affairs may have already moved
on since my snapshot of the situation at one point in time.
• It was written by one person and reviewed by only 2-3 others – all from the Centre. These 3-
4 people determined the scorings and weightings of the options as best they could. What if
those in the field had a different opinion - what would happen to the numbers and the
attractiveness of various options?
• From what I was able to ascertain, there was very little input from the ERDIP sites, from
those in the field who are facing the day-to-day clinical information realities, from the
clinicians who are critical to the success of any EHR, and from the suppliers on whom
everyone is depending on to build EHR systems.
• To my knowledge, no one visited (or at least surveyed) the nine ERDIP sites working on the
Emergency EHR to determine to what degree they are achieving the benefits described in
section 5.6.5 of the EHR SOC.
• I personally do not consider presenting a proposal to a committee such as the Medical

Informatics Group as well-versed consultation. I have sat on enough such committees - as

well as presented to many of them - to know that doing a quick read the night before a
meeting and taking part in a discussion (no matter how long) is not the same as taking part in
a series of intensive workshop-like sessions, with many people involved, to hammer out
common understanding and consensus. If I have ‘read’ this wrong, I apologize and am
prepared to stand corrected.
• It appears as if most of the preferred options in the EHR SOC point to a national solution with
an implied ‘push’ model. What about a ‘pull’ model whereby the EHR is virtual and does not
exist in physical form in one place? What about a mixed model where messages are ‘pushed’
when new data is available and ‘pulled’ when the details of that data are needed? What about
an ASP model which has the potential to eliminate the distinctions between primary,
community or acute care, let alone mental health and social care? England should not feel all
alone on this one. The New Zealanders just published their national strategy. It is intriguing
to see that they are also caught between the centralised and distributed models as well as the
push or pull paradigm dilemma.
• When it was written, IfH explored the different technologies underlying the “data-push” and
“data-pull” models but concluded that the “data-push” model would provide the fastest route
to a first-generation electronic health record. However, in the three years since publication of
IfH, there have been significant advances in the spread of web-based technology, and the
adoption of national interoperability standards (such as e-Gif). Some would argue for an
EHR architecture based on the “data view” model – using XML as a standard and more
widespread access to and use of the Internet.
Despite being published openly for comment, only 14 people provided feedback to the EHR SOC; of
which 6 were but brief e-mails. Appendix H highlights some of the more salient points raised
including:
• The Exeter system is an existing example of a national system implemented at local level.
Should work not be done to identify if Exeter, with modifications, could provide some of the
functionality required to support the emergency care EHR, providing the “bridge” between
local / health community EHRs and a national EHR application / portal? Open Exeter
facilities already provide some links into the Exeter population data by Trusts and GPs.
• Current plans outlined in the EHR SOC involve a lengthy specification process, culminating
in a national procurement with appointment of a contractor in 2002 – leaving only a year for
full national implementation. To attempt to move from a number of small-scale ERDIP
projects direct to a national rollout without a large-scale pilot to demonstrate effectiveness
and scalability increases the risks of failure.
The ‘preferred’ option in the EHR SOC appears to involve using NHS Direct CAS as the basis for the
Emergency EHR. Is there any solid evidence that CAS (which is primarily a decision support tool) is
technically capable of handling both the functionality and transaction volumes that a national EHR
will demand?
Has the business need for the EHR been clearly established? Is the priority of the EHR to be the tool
to assist in the day-to-day delivery of care - particularly the so-called emergency care? Or is its main
intent to be providing the data to support clinical governance and other retrospective analysis?
Answering this question one way will lead the journey in a very different direction than the other –
even if the two paths may eventually end up at the same destination. As an example in the former

case, a ‘messaging’ paradigm could be used where messages would not even need to be structured. In
the latter case, clinical governance will require much structure in order to assure consistency, quality,
etc. for benchmarking purposes.
There is a need to learn from what has happened to date and look beyond IfH in order to ensure that
the EHR journey is still on track. Once there is an acceptance of this, then the debate about what’s
in/out of EPR/EHR will change as people realise they are themselves interim steps on the way to
something more close to what today’s clinicians and patients would be expecting.
I believe many would agree that it is critically important that someone from the business side of the
NHS – someone who is able to go across traditional boundaries - has to take ownership of the EPR
and EHR agenda. It should be an individual committed to actively supporting a strong project
management and change management agenda. Some would argue that the individual should be a
clinician. What is clear is the overwhelming evidence that those who will ultimately benefit from
them - rather than the IM&T professionals - must lead information systems initiatives. The role of the
latter should be to support and advise, not to lead.
Finally, leading the EHR effort is more than a full-time job; it requires a dedicated team of people.
Expecting one person to prepare the plans and lead the discussions on a part-time basis is both
unreasonable and a recipe for failure.

6. RECOMMENDATIONS
The following recommendations are not ordered in a long-term and short-term fashion. They are
presented in what I view as being the most logical order to address the issues - fully appreciating that
what may be logical to my mind may not be to everyone else’s.
1. Harmonise the many performance management targets.
The IPU, perhaps through the National Information Policy Board (NIPB), should attempt to have
all of the service (business)-oriented targets rationalised and harmonised.
The performance indicators overload of the NSFs, Cancer Plan, etc. is, in my opinion, a serious
problem. There are too many of them and they are not mutually exclusive. When some of my
colleagues in academia (a profession which is paid to keep abreast of materials such as NSFs) find
they cannot read all the details of the NSFs plus run their courses, there has to be some cause for
concern. If the universities have difficulty in finding enough time to include all of them in the
curriculum, one can only wonder how those in the field are coping.
Those trying to do their day-to-day jobs looking after patients in times when demand continues to
exceed supply also regularly have to cope with the pressures brought on by staff shortages as well
as the explosion of knowledge about medical science including new procedures, drugs and
technologies. Such is the case with health care providers and managers the world over. In the
UK, these same providers and managers have the additional performance measures to deal with.
2. Bring together all of the EHR-related initiative leaders.
Under the auspices of the NIPB and facilitated by the IPU, representatives from the 40+ EHR-
related initiatives (Appendix E) should be solicited to attend an important knowledge sharing and
priority setting meeting. In addition, representatives from Local Authorities (LIP authors),
Scottish Health Executive, PPA, CHI, and the e-envoy’s office should be invited to participate. It
might also be of value to include representatives from the BMA and professional colleges as well
as representatives from the private health care sector to join in.
Have each EHR-related initiative leader identify the purpose of their activities and how they
perceive each activity might associate to the emerging EHR. Consider this to be an expert
advisory group to the IPU. After they become familiar with what everyone else is doing, invite
them to identify inter-dependencies (how do their pieces fit together with others) and even set
some priorities. Ask them to identify where the greatest NPV is – i.e. the Net Patient Value. An
expected outcome of this process should be to amalgamate and preferably defer certain initiatives
for a period of time.
In my estimation, there is a pressing need to reduce the number of developments and initiatives.
There are a number of relevant initiatives for integration and greater inter-working – one example
being the clinical context, datasets, messaging, headings, and terms projects. It would be wise to
focus down on a number of key initiatives in the next two years to bolster confidence in what is
being done by making demonstrable improvements for staff and patients. There is a risk that
vertical (national) projects may impede local communities moving on the important horizontal
projects vital to supporting NSFs.

It is particularly important to synchronise both the policies and the messages emanating out of the
IPU, the NHSIA and the Primary Care Branch of the Department of Health. In my opinion there
is confusion as to who holds the policy responsibility for many of the existing initiatives. There
continues to be uncertainty as to who should be out regularly 'beating the drum' and actively
promoting IfH throughout the Service.
The importance of these three entities working very closely together, and in complete harmony,
should be acknowledged to be one of IfH’s most important critical success factors. The same
synchronicity and partnership should be evident from Health and Social Services.
It is inevitable that clinical governance requirements will require structured data and hence the
clinical datasets projects. One cannot help but notice that the dataset projects do not appear to be
fully coordinated and that the so-called ’minimum’ data sets are bordering on being maximums.
It is also disappointing to see how little SNOMED CT appears to be taken into consideration in
the dataset projects. The model in Appendix I has been suggested in Canada as the ‘proper’
number of minimum data elements that all health information systems should collect. If this was
agreed as being generic and common to all clinical datasets, significant progress will have been
made.
In my humble opinion, there would be no harm and significant value to take a very hard look at
the way the Scottish Health Service has approached the implementation of IfH. One is reminded
of Tom Peters famous book “In Search of Excellence” which argued that small is beautiful.
Scotland seems to be small enough to make things happen reasonably quickly, yet big enough to
devote sufficient resources. Does this provide the English with any indication as to what might be
the optimum size for certain classes of projects?
3. Revisit the Information for Health targets.
The Department of Health should acknowledge that, for a variety of real and very valid reasons, a
number of the original Information for Health targets are no longer achievable in a meaningful
way and should be revisited. There is no shame in this, indeed it is a sign of a mature organization
that can reflect and adapt to its changing environment - is it better to fail on time or succeed later?
There is a need to explicitly tie all of the EHR and information-related targets to the business
needs and targets described in the NSFs and the like. There is an equally important need to work
out what the "corporate NHS" can afford to do. There should be an implementation plan that
brings together best guess costs for the implementation of any target. If it is known what is
available to spend and what the cost of each target is expected to be, the Centre can make sure
that they are not promulgating unrealistic expectations that cannot be funded.
The performance management of LHE progress on clinical targets should include progress on
electronic records. An example might be to ‘score’ them on how many event records they expect
and were actually contributing. A LHE would get a green light for progress on CHD, for
example, not merely for demonstrating agreement of local clinicians to design and
implementation of clinical pathways but also for demonstrating firm agreement to supporting
these pathways with electronic record development. Without the EPR/EHR systems the verdict
would be a red light. This approach would most likely be welcomed by local clinicians, many of
whom who recognise that electronic systems are essential but are frustrated by lack of progress
towards them.

There is a need to collect group disease pathway data (e.g. cancer) – a need, which was not
present, when Information for Health was written. Clinical care networks are fundamental to the
modernisation programme.
If true integration is to occur, the LIS and LIP processes and targets need to be integrated within
the new StHA framework – another illustration of something that was not present when IfH was
written.
4. Revise the level 3 EPR targets.
The IPU, in active partnership with the NHSIA, should reframe the level 3 EPR targets into a new
set of unambiguous targets that relate to providing specific functionality across the entire care
spectrum of primary, secondary, community, mental health, and social care. Consider the
following to be the priorities:
1. Results reporting: who needs to know what happened to whom – consultants, GPs, social
workers, nurses do
2. Order Entry: who needs to do what for whom – use of protocols and common order sets
as well as the humdrum, but essential, day-to-day communications across sectors such as
referral letters
3. Medication Prescribing: with built-in alerts and reminders (level 4) for both physicians
and nurses
4. Enterprise-wide Scheduling: who needs to go where and when – again across all care and
organisational boundaries
5. Integrated Care Pathways: what has to be done for whom – complex in terms of changes
to workflows
The rationale for this ranking is that the suggested order provides the least cultural change and
hence the least amount of impact on the work lives of health care professionals. It has been well
documented that results reporting is likely the most important of the five functions – pathology
messaging being a classic example. This ranking also provides a guide for those organisations
that do not have any of the above functionality. For the more advanced, they could well already
be undertaking all five.
A counter argument could be made that the number one priority should be care pathways given
the importance placed on them in the NSFs. However, as put so well by one of the interviewees,
“Integrated care pathways are inherently much more complex than protocols inside one Trust and
we have made little progress in getting our clinicians to share these!”
The increasing influence of the Leapfrog group in the United States (a coalition of 80 major
companies with a combined total of 26 million employees) is a powerful motivator to place
Computerized Physician Order Entry (CPOE) and medication prescribing higher than scheduling
and pathways. In order to meet Leapfrog’s CPOE standard, American hospitals must:
• Require physicians to enter medication orders via computer linked to prescribing error
prevention software;
• Demonstrate that their CPOE system intercepted at least 50% of common serious
prescribing errors, using a testing protocol specified by First Consulting Group and the
Institute for Safe Medication Practices;

• Require documented acknowledgment that the physician read the directives to any
override.
The coalition has taken the remarkable step of offering millions in cash incentives to hospitals that
adopt patient safety practices. The unprecedented move was sparked by employers’ frustration
over the rising number of medical errors; researchers estimate that between 15,000 and 90,000
people in the U.S. die every year from medical mistakes.
The evidence to support computer-based medication prescribing continues to mount. A recent

Norwegian study reported that drug-related side effects might contribute to nearly a fifth of all
hospital deaths in elderly patients, particularly those who have more than one illness or are taking
multiple medications (Gottlieb article). In almost half the cases looked at, inappropriate drugs
were prescribed or the wrong doses or forms of drugs used.
Generic scheduling across the local health economy of complex health events (not just a pathway,
but the actual scheduling rules) will bring significant benefits. At the moment, most hospitals
tend to think in terms of scheduling (with referral protocols) for just outpatient appointments or in
some cases theatres. But in the new NHS there will be a vital need for enterprise-wide scheduling
that extends across the LHE and clinical care networks.
A state-of-the-art scheduling system needs to offer not just more functionality than traditional
systems but must also support for distributed scheduling handled by a variety of healthcare
providers and even patient themselves. This can only be achieved if the system is both web-based
and rules-based. What is needed is software that provides flexible template and programme
definition; authorisation of bookings through fully customisable protocol-driven booking forms
and appointment-type parameterisation; the ability to generate instructions for patients, GPs,
nursing staff and other care professionals; support for sophisticated load balancing and case-mix
management within clinics; conflict handling; and an effective approach to access rights.
It should be noted that this recommendation is not meant to deter those leading sites that are
already at or beyond ‘level 3’ EPR. They should be given special support to assist them in
pushing the EPR envelope even further so that others who follow will have an easier journey. It
does, however, recognise that a number of recently merged Trusts will be happy just to integrate
their PAS systems (level 1) in the next few years, let alone start in on level 3 EPR requirements.
Has any thought be given to concentrating EPR efforts on the larger Trusts that account for 80%
of the NHS business?
5. Refocus the EPR-EHR model.
The original concept of the EHR being a longitudinal health record is still very valid! However, it
has become entangled in organisationally bound thinking. The IPU and NHSIA partnership
should develop a true patient-centric model. The aim should be to avoid the disruption that occurs
as a result of organisational restructuring.
A new paradigm is needed to support the single assessment process outlined, as an example, in
the NSF for Older People. It recognises that many older people have health and social care needs,
and that agencies need to work together so that assessment and subsequent care planning are
person-centered, effective and co-coordinated.

If a conceptual mind shift does not take place, there is a grave risk that both the EPRs and the
EHR will be built on increasingly obsolete concepts of inpatients and outpatients; historic models
of face-to-face, hospital-based, consultant-led service delivery; and existing organisational
boundaries. They will not meet the challenges being faced of multi-professional, multi-
organisation patient pathways, NSFs and clinical networks. The EHR needs to be a patient/client
record that is independent of the institution providing care at a point in time along the
patient/client pathway(s). This would seem to be in line with “an NHS designed around the
patient”.
Patients will be accessing their own records – it is only a matter of time. The current
institutionally based record is not going to permit this with any degree of ease or commonality.
This requires a significant change of thinking of the patient as a customer – not something we do
well in health care anywhere in the world though the Americans seem to be getting better at it.
The Bury Knowle project found that patients are surprisingly receptive to the idea of taking a
more active role in the management of their health and that they are prepared to become more
engaged with health professionals in the neutral ground offered by the EHR. In addition, health
professionals are interested in the development of the EHR and its potential to allow the health
professional in partnership with the patient take full advantage of the improvements in medicine
that current information technology can deliver. The interest in the EHR expressed by patients,
GPs and other health professionals indicate that should a viable, affordable, scalable, and
functionally acceptable EHR system be made available, it would significantly improve
communication and reduce the present duplication of record keeping
I perceive that the rapid development and implementation of clinical care networks is creating a
frustration due to the recognition that the individual institutional components such as acute EPRs
do not fit well together to support networks which span secondary and primary/community care
settings. There is a danger that clinical care networks will attempt to create solutions based on
their particular condition, changing institutional silos into condition-based silos. Any solution
must recognise that at any point in time the individual patient may be traveling on none, one or
more pathways and interacting with none, one or more service providers. Patients must have the
right to protect the privacy of information, but they equally have the right to expect that where
they have granted consent, the service providers will provide their care in an integrated way.
Consider adopting the term “unified electronic care record” or “integrated care record” – the
distinction being that it covers social as well as health interventions, and gets one step away from
the notion that it is a record made by the professional about the patient at an intervention – it can
equally be a record made by the patient about their intervention. Does the word ‘electronic’ even
need to be included – can it not now be implied?
There is a clear national policy aim of the integration of services across health and other public
services, most notably social care. In some fields - especially mental health/learning disabilities -
NHS staff is increasingly working from local government premises and vice-versa. In some cases
services is the responsibility of one party but largely delivered by another. However a very
practical issue arises when local attempts to ensure staff have access to the network services they
need run up against the NHS network connectivity rules. This will raise the debate about the
inequality of funding and performance management arrangements and different policies - for
example where local authority staff are not allowed access to the Internet, while their NHS
colleagues working as part of the same team are.

This brings up the question of where the NHS boundary lies and whether the concept of a NHS-
only network has any meaning in the future – particularly given that local authorities will be
pushing for networks, which crisscross traditional boundaries. As reported last year, some are of
the opinion that the Internet will become the common vehicle – even for ‘confidential’
communications.
This also raises a thorny issue - who runs the agenda across health and local government
boundaries? No easy answer but a key topic that needs resolving in the future. Solving this one
will require tact and diplomacy - one certainly cannot assume that the NHS is going to be able to
dictate to local government.
6. Develop a portal (broker model) to address the political need for an ‘Emergency’ EHR.
The NHSIA should be directed to make patient medication data available to all authorised A&E
physicians, NHS Direct nurses and OOH GPs via an ‘Events EHR’ as soon as possible.
They can build this new functionality, the Events EHR, on one of the most solid and reliable
systems foundations the NHS has, the “Exeter” system. It would take immediate advantage of the
fact that GP systems already electronically send data to Exeter. Although the aim of the original
Exeter system was to support patient registration in the context of GP reimbursement, I do not
believe that it would be a major technical or cultural change to also have GPs send to the Exeter
system details of the patient’s allergies and medication data – data that is currently captured in
many GP systems. This medication data could then be made available to all authorised
‘emergency’ personnel – with an accurate audit trail of who accessed what. It could also prove
very useful for clinical governance – particularly in terms of chronic disease management and the
analysis of repeat prescriptions. Ideally this new functionality should be fully integrated with the
Electronic Transmission of Prescriptions (ETP) project and make use of a national drug
dictionary.
Appendix J diagrams what could be done, starting with the adoption of web-based browsers and
XML interfaces as a national standard. This recommendation is not all that innovative – it is in
essence an early manifestation of option 7 in the Populations Records SOC.
The patient consent issue could be dealt with by having the patient give their consent when they
visit their GP. GPs would then only transfer medication data of patients that have given their
consent. There are apparently a number of GP practices and OOH services that would be happy to
serve as pilots to prove the concept and the approach. I would expect that convincing evidence
could be demonstrated within six months. Once proven, the medications prescribed by
consultants prior to a hospital discharge could be added to the Events EHR.
In subsequent phases of this development - if an ‘Events EHR’ is deemed to be useful (based on

the findings of the ERDIP programme and a review of the EPR/EHR model) - additional clinical
data could be added such as:
• Inpatient and outpatient events on their way to NWCS from PAS systems - in a quicker
fashion than the current circumstances and with or without the discharge diagnoses
• Booked admissions as the electronic booked admissions program is rolled out
• Referrals (waiting list) events as electronic messaging becomes the norm
• NHS Direct events – perhaps not all of them

• An alerts capability to warn healthcare providers of the presence of any known risk
factors that may be important in making clinical decisions about individual patient care
• Etc.
Such an events EHR would go a long way to satisfying several of the NSF requirements, let alone
an expanded clinical governance program which will inevitably stretch beyond the existing
organisational boundaries and begin to address outcomes. It would also address the need for
information about where a given patient has been and is going – a common requirement with
those dealing with ‘unplanned’ situations. It would also provide the test bed for a common portal
that everyone would go through for all NHS transactions.
Clearly the consent and confidentiality issues would have to be fully resolved. It is suggested that
the consent and access management function be put under the auspices of a new ‘Certificate
Authority’ acting as an independent, public or private, trusted third party. The Authority could be
structured similarly to a commercial trusted third party in electronic commerce. One such
example is Wells Fargo, partnered with GTE CyberTrust, which offers a digital certificate service
to Internet merchants. Though more and more customers are spending time browsing online,
many are not comfortable enough with Internet security to make a purchase. With parties such as
GTE CyberTrust, they can be provided with that security assurance.
Along the line of ‘trusted third party’ thinking, in British Columbia, Canada, the College of
Pharmacists have been designated the legal custodians of the provincial pharmaceutical database
which contains the medication profiles of all persons who were issued medications in all retail
pharmacies in British Columbia – a database which has been used to save lives in A&E situations.
All accesses to the database, including any Ministry of Health access, must be vetted by the
College of Pharmacists. Anecdotal evidence suggests that the public is more comfortable with
this arrangement than if the Ministry controlled access.
From an infrastructure perspective, a speeded up effort by the Centre in a number of important

standards areas will be needed to make this work, namely:
• NHS number activation in all NHS systems – treat it like an Y2K project!
• National directory of healthcare professionals – perhaps to be maintained by the GMC
and other professional bodies – with standard forms of SMTP e-mail addresses and a
single log on – possibly to be integrated with the new national payroll system
• National directory of sites – expanding beyond the existing organisation codes and
integrating the somewhat independent efforts going on in the PPA, NHS Direct, NeLH,
and nhs.uk
• National consent and access management
• Quicker transfer of inpatient and outpatient data into NWCS
• Development of a unique referral/pathway/booking identifier to allow the differentiation
between threads of data associated with the individual patient at a single point in time
• Backup and security including audit trails
• Technical standards (e.g. HL7, XML, etc.) - standardised distribution frameworks
(middleware) have become ubiquitous; these include RPC, CORBA, DICOM, and more
recently .net and SOAP
The Internet Request for Comments documents provide an excellent example of the use of
standards to ensure compatibility and compliance. Is this the primary role for the IPU and the

NHSIA - to foster and develop the standards that define how information will flow between
systems leaving it to the user community to develop the enhancement in functionality and
effectiveness?
It was also not clear how much progress has been made rolling out the NHS Number across the
country. It was clear that every citizen did not have a plastic identification health card that they
should then be expected to produce at any encounter with the NHS. The EHR is not likely to
become a certainty unless all NHS organisations incorporate the NHS number into all of their
clinical systems.
Regardless of what form it takes, the EHR will require some form of NHS-wide Master Client
Index (MCI) - some prefer to refer to it as a Master Patient Index. Every patient records system
and more generally every patient/client/citizen-focused system has at its core a client index. This
absolutely critical infrastructure piece must be up, running, and rock solid before any patient-
centric benefits can hope to be realised. The common patient index is a cornerstone of any EHR.
A MCI accommodates multiple identification numbers for each client and reflects encounters at
different health and social service facilities and/or programs. These organisationally based
identification numbers will not go away and they will need to be kept track of somewhere – at
least at the LHE level, if not at a national level. The key identifier in the MCI should be the NHS
Number – the already established universal health identifier for every British citizen within the
NHS. The many existing facility-specific identification numbers need to be cross-indexed within
the MCI in order to locate and retrieve data from records in systems in multiple facilities.
England is very fortunate that it has the makings of a national Master Client Index, through its
existing Open Exeter and NSTS population-based systems – two national systems that will
undoubtedly be fully harmonised in the near future. What is needed is a standard way for every
NHS organisation to have on-line 24/7, authorised and audit trailed, access to a single source of
patient/client demographics and the contact details of the client’s current GP. In emergency
situations, authorised clinicians should also have access to the patient’s current medications and
allergies.
Progress was noted on a new code of connectivity that removes the barriers to legitimate access to
any NHS data. It was not clear if progress had gone as far as removing the existing ‘restrictions’
that one Health Authority does not wish any other Health Authority to see “its” data. All of the
data in Exeter and NSTS systems - and any other NHS system - should be viewed as NHS-wide
corporate data and hence accessible to anyone who has a legitimate need for it.
Development of a national health care professional registry will go a long way to assuring that the
increasingly important aspect of consistently identifying the health care professional who actually
delivers each element of care – as distinct from only the GP and/or consultant with overall
responsibilities. It cannot be overstated how important key national directories are needed – the
professional registry being but one of them. If the national EHR is ever going to become a reality,
it seems inconceivable and unnecessary for each NHS organisation to maintain its own set of
directories.
The EHR, in whatever form it takes, will need to be accessible via a single login or sign-on, one
which eventually will permit any clinician to access any system in the NHS from anywhere and
ideally in the same way (desk tops with a common look and feel) – as is the case in most large
private sector corporations.

This recommendation suggests that the Centre concentrate its standards efforts on key
infrastructure elements such as: national directories, an even more reliable and robust NHSnet –
building on the progress made as outlined in the NHS Infrastructure SOC, single logon ids, access
rules and consent protocols, etc.
7. Advise the field to concentrate on the basics.
While the Centre is concentrating on infrastructure standards, the Service will undoubtedly be re-
organising their service delivery models to encompass the new pathways (some would argue this
should be done before any automation takes place).
Assuming that the Centre still wants a national strategy that is implemented locally, the Service
should be strongly encouraged to concentrate their efforts on:
• Culture change – a critical success factor, regardless of what type of EHR emerges. IfH is
very much about change. It is about changing the way work is done. It is about changing
behaviors - particularly information behaviors. Changing information behaviors requires
change management approaches and thinking. The ultimate goal of managing information
behavior is to create a positive information culture - one where it's simply the norm to "do
the right information thing". Are there still ‘over my dead body’ clinicians and managers
around?
• Training (enough is never enough) – across all sectors including GP practices. It is so
very easy to cheat on training yet when done well, it reaps rewards well beyond the
investment costs. If the IM&T solution does not match workers practice and
comprehension the tail will wag the dog. What percentage of the NHS workforce is
comfortable and proficient with web-based technology? It takes time to build up
information expertise and knowledge at different levels in an organisation.
• Data quality – so fundamental it seems a waste of space to even mention it yet it is still an
underlying problem in many systems. Clinical governance, NSFs, and NHS Plan will all
be undermined if the NHS does not make a concerted and continuous effort on data
quality. Should the PRIMIS program be expanded to assist professional groups in other
sectors (e.g. community nurses)?
It is difficult to provide explicit guidance to the primary/community (non-hospital) sector in

selecting and/or upgrading their EPR and information systems as there is no single organisational
community model. In some instances, community clinicians’ work in a combined
acute/community Trust, others are aligned with a GP or a group of GP practices and yet others are
working for a dedicated community Trust. Can anyone realistically, at this time, advise these
groups to build their EPRs on existing or new GP systems, on community health systems, or even
on acute Trust systems? There are many potential directions of travel and any given one may not
be ‘the best’.
There is a dearth of information to support the development of the PCT clinical system market.
Few PCTs have a firm idea yet of what is needed or wanted from a customer perspective that is
not surprising, given their short existence. Suppliers are unlikely to lead developmentally as they
risk significant revenue loss as the market develops. The most likely outcome of this will be
market uncertainty - a prevalence of tactical rather than strategic decisions and a failure to achieve
either maximum clinical effectiveness or value for money through the use of technology.

That being said, there is still sound advice that can be given which applies to any organisational
model:
• Cooperate with as many organisations in their LHE as possible in order to facilitate

greater sharing of patient data. At a minimum, ensure that there is a collaborative
planning process (through the LIS or its equivalent). There is clear evidence that staff
working locally across GP practices benefit from a familiar system interface, shared
protocols and templates. It encourages and enables the use of practice-based systems by
community nurses in particular.
• Ensure that sensible first steps are taken (e.g. encourage PCTs to bring together GP
practice systems) – realising that gaining and retaining clinical commitment is so
important that anything that puts that at risk (e.g. imposition of a central solution) has to
be looked at in terms of the pain/gain. Clinicians are more interested in ROT than in ROI.
It is the Return On Time that is most important to them.
• Investigate the use of e-mail technology (Knight article). Some trusts have been able to
utilise their e-mail system far beyond a messaging system – such as into supporting multi-
disciplinary care. The raw ideas, prototype and experiments that can be facilitated through
e-mail can become more robust through more mature IT systems. The organisational
learning and development that can be achieved through this simpler approach can be
invaluable.
• Adopt systems that simplify people’s work lives, e.g. why do GPs have to use so many
different forms for ordering and referrals?
• Select systems that facilitate the flow of data within the LHE and, in particular, results
reporting. An important data flow between all clinicians, regardless of their setting, is
referral and discharge data.
• Adopt systems that are able to deliver simple, accurate and timely reports to users.
Community health staffs, in particular, have endured many frustrating years of entering
data into systems with little or no feedback to inform clinical practice, let alone clinical
governance. The use of technology should be applied as support to the clinical processes
(as per the original IfH strategy) and not be perceived as an additional and reluctantly
applied ‘extra’.
• Introduce interim clinical dataset collection systems that minimise duplication of effort by
maximising the use of data that already exists.
• Adopt person-based data systems (using the NHS Number as their primary key) that
provide support for clinical activity/care episodes that record the patient experience and
collect a minimum data set (Appendix I) for each event.
• Adopt common registration systems - based on a LHE MPI - so that everyone in the LHE
(Trusts, OOH, walk-in centres, etc.) is using the same approach to registering their
clients/patients.
• Adopt web-based systems and the use of XML interfaces in order to facilitate
communication with other systems.
• Give serious consideration to systems which function on an ASP model so as to minimise
capital costs and human resource issues – they may indeed be the way of the future
notwithstanding the perceived confidentiality concerns.
• Build audit trails into all systems and more importantly set up mechanisms to use them.
In the end, would it not be better for a LHE to work slowly but collectively in improving
information systems in support of patient pathways than for an acute Trust to achieve level 3 EPR
status while the rest of the LHE remained in mediocrity?

8. Address the patient consent issue.
As indicated earlier, this could be the major barrier to an EHR becoming a reality. Even if part of
the final solution is revised legislation, it seems apparent that in some form or other, the consent
process is going to have to be automated. The NIPB, in conjunction with the Information
Commissioner’s Office, should aggressively pursue resolving this very important matter.
As is suggested in the model in Appendix J, it would seem to make sense to have the patient
consent (and EHR access) managed nationally – likely as a part of the client registry whereby in
addition to the client demographics, there is also an individual’s access approvals. Alternatively,
the EHR might include a statement of informed consent electronically signed by the patient or
legal or voluntary advocate that states who can and who cannot see the record - subject to
legislation and clinical governance. This might be altered at any time by the patient with an audit
trail of the change maintained.
If any lesson has been learnt from the recent Bristol case, it is that informed consent and trust is
paramount. There is no doubt that data on electronic databases will be subject to some misuse
and breech of confidence. It seems essential then that patients have the right to give or deny their
informed consent to disclosure of their data. Informed consent implies the understanding of a
patient or their legally accepted guardian of the risk and benefits of a treatment or process.
Undoubtedly, special attention will be needed to deal with the so-called four unmentionables,
namely: social factors including mental, personal relationships etc., drug and alcohol abuse,
genetics, and communicable diseases. Similarly, the data about children at risk will require
careful managing. It is likely that national legislation according to public interest will be needed
to allow clinical team leaders to override inappropriate patient denial to access. Caldicott
guardians will likely be the ones to bear the responsibility for decisions about access when
consent prevents clinical care being undertaken appropriately.
The national Child Health System in Wales has apparently addressed a number of these issues –
including the confidentiality between local authorities and the NHS for special needs children.
Do they have the framework on which to build a national solution?
While developing an approach to consent management, acknowledge that the Internet-based

Personal Health Record (PHR), in some form is going to become a reality. One way or another
there is going to be a need to provide a secure web based front-end for patients to view the records
created by health professionals. In addition there is going to be a need to support patients entering
in their own data / notes. It is inevitable that the professional, will then view this data - with
patient permission - thereby creating a two-way relationship between the patient and professional
view of the records. Whether or not this impending PHR is eventually housed within NHS Direct,
Bill Dodd’s Health Information Bank idea just does not seem to go away does it?
9. Mandate a standard that all NHS computer systems have an audit trail.
A tremendous amount of public and professional bodies anxiety would be dissipated if all NHS
organisations, regardless of whether they are in primary care, secondary care or elsewhere, were
regularly recording who is accessing (including viewing) what data. In addition, all organisations
should be expected to make use of the audit trail data to monitor who is accessing what data. The
IPU should send out guidance on this subject as soon as possible.

This process need not be resource intensive or time consuming. Every night, each system could
produce a report of ‘unusual’ occurrences – based on predetermined algorithms. If someone
(perhaps the Caldicott guardian) looked at and acted upon the report the next morning (even if
they only randomly selected 3-4 to pursue), the number of incidents of ‘browsing’ would drop
overnight. Word would spread quickly that someone is monitoring accesses to patient data and
everyone would be more conscious of only accessing patient data that they required to perform
their duties.
Along the same lines, insist that data be protected in some fashion, that no unencrypted
(personally-identifiable) data is sent over the Internet (or NHSnet). Until a national (likely
government-wide) encryption standard is selected, and even if it appears that there are not any
PKI products which are going to be suitable for such wide-scale deployment in the near future, an
interim strategy of making “local” solutions fit for now is called for.
10. Develop an active and vibrant Knowledge Management (Learning) Program.
Knowledge Management is about creating a learning environment where knowledge sharing is

part of the culture. Learning is fundamental to enhancing local creativity and national
cohesiveness. In an information-intensive service such as healthcare it is a “must have” - not a
“nice to have”. It is critical to information sharing and a common direction. The NHS needs
tools to support real knowledge sharing so that it can become a real learning organisation based
on evidence of what works and what does not. Otherwise, the result will be fragmented systems.
The NHSIA, in collaboration with other organisations such as NeLH, should be commissioned to
get on with this important initiative.
Organised experimentation is a key component of the EHR journey. Even the brightest group of
experts cannot sit down and devise the “right” strategy. The key is to focus the efforts and share
the results of the proven practices – including a much more serious effort to study what is working
well in Scotland.
The Government is committed to learning. The NHS Plan (section 5.17) states that “We will
ensure more help with personal development and training: by investing an extra £140 million by
2003/04 to ensure that all professional staff are supported in keeping their skills up to date and to
provide access to learning for all NHS staff without a professional qualification”. The challenge
faced by many NHS organisations is to protect the time to learn.
When information is everywhere, the commodity in shortest supply is attention. Clinicians and
managers have access to far more information than they can possibly pay attention to. New
sources are appearing all the time but the old sources have not gone away. Information overload
is very real in health care everywhere, and perhaps even more so in the NHS. While information
providers have previously viewed access to information as their primary goal, access is not
enough. The real challenge is to communicate information in a compelling way that encourages
the right people to recognise and use it.
Educational institutions should play an active role in a variety of ways including offering IM&T
specialists and others a forum to share good practices. The development of the NHS Electronic
Library could also include a special section on IM&T developments and practices. Undoubtedly
the office of the e-envoy would also have an interest in moving this particular agenda forward
aggressively.

The Knowledge Management (Learning) Program could start with building a clearinghouse of
information-related activities underway in the NHS. The clearinghouse would have an effective
indexing system such that inquiries could be made of the database to identify who is doing what
and what their experiences (lessons) have been. It is what Davenport refers to as an information
map – something simple but highly effective to enhance communications within an organisation.
Mechanisms would be developed so that those submitting data to the clearinghouse would have
powerful incentives to keep their content both current and accurate.
The clearinghouse would provide a BMJ-like push service that informs anyone who signs up of
new materials – based on their specific interests – that have been added to the database. A la
BMJ, an e-mail would automatically appear which displays a series of titles, followed by a short
paragraph for each title and then finally a hyperlink to the full document. The short paragraph is
key to a successful push service. It needs to be written by someone who can analyse and
synthesize the significant aspects of a document.
It may make sense to start with the ERDIP program though some may feel there is a greater need
to document what is going on across the country in non-ERDIP sites - back to the original ERDIP
brief.
It was reported last year that most ERDIP sites did not have an appreciation of the mechanism to
work with other ERDIP sites. Those who were collaborating were for the most part doing it on
their own volition as a result of personal contacts - hence some ‘re-inventing the wheel’ was
occurring. Noticeable progress has been made on this front but much more could be done.
11. Revise the Requirement for Accreditation (RFA).
The Primary Care Branch of the Department of Health, in partnership with the IPU and the
NHSIA, should revisit the RFA at the level of first principles. Simple extension of the current
model to simply PCT systems would likely be damaging. Abolition would be equally counter-
productive, as it would lead to a proliferation of non-standard systems. Instead, the RFA should
be considered, as a more focused tool to manage the current market situation – across all sectors.
It appears as if not all existing GP systems suppliers are committed to the ‘sharing of patient-
identifiable data’ paradigm, which is absolutely critical to the EHR becoming a reality. In fact to
say that some of them were being ‘obstructive’ might be too kind. There is a very real
apprehension amongst GPs that they cannot switch suppliers – it would be wise to put policy and
practices in place to eliminate this trepidation.
The next RFA issuance should be quite explicit about system interoperability and data sharing
expectations. This will likely require a rethink in terms of the undue influence that some suppliers
appear to have on the accreditation setting process. Many in the field seem to have the outlook
that the RFA has been transformed into a barrier for entry and has, in particular, imposed
restrictions on data extraction/sharing functionality.
In the process of finalising the next RFA, the fact that some suppliers are supporting 9-10 versions
of their systems should also be addressed – the NHS is paying for this ‘freedom of choice’. In
fact, a strong case can be made that one can have value for money or freedom of choice but not
both.

12. Let NHS Direct get on with their agenda
Fully appreciating that I did not spend a great amount of time in and around NHS Direct, I
nonetheless am of the opinion that they should not be burdened with the EHR (even the
emergency aspects of it) at this stage of their development.
NHS Direct have enough on their plate developing the decision support aspects of CAS as well as
merging their databases onto two servers. They should be focusing their energies on integrating
their services with OOH services in their regions – all very important capabilities needed to make
their service all that much more valuable to the public and to the NHS. Some have suggested that
NHSD should focus on providing a top quality service ‘channel’ not on creating and managing
‘content’.
NHSD should be given access to NSTS/Exeter in order to obtain basic patient demographic and
GP details along with the aforementioned medications data in the ‘Events EHR’. This will assist
in situations when the NHS Direct clinician is able to provide the ambulance services with key
information about the patient.
13. Push for a Chief Information Officer (CIO) position in the new StHAs
The IPU should do all it can to convince those setting up the StHA infrastructure that someone
should be given the remit to maintain the benefits of cooperation that have begun in the LIS
communities. For those LIS communities that are not working, it would be an opportune time to
review their boundaries. What is important it seems, is maintaining the integrated efforts that the
clinical care networks will be depending on.
I fully appreciate that there is a major selling job to be done here, as the focus for StHAs seems to
be on strategy development and performance monitoring. IM&T is apparently not on their radar
screen. To complicate matters it is likely that the StHAs will be preoccupied with their own
organisational development for 1-2 years. The Department of Health restructuring includes the
statement “Plans are in hand to appoint a patients’ champion, an Information Director and an
advisor on private partnership from outside.” Why not Information Directors in each StHA?
Surely the success of the StHA themselves – let alone those providing patient care services - will
be highly dependent on quality information.
The position of CIO is most common in private sector companies though it is increasingly
appearing in American and Canadian health care organisations. The need for such a person has
evolved because the management of information has changed drastically in the past 30 years. In
the early years, the big job was to manage the technology - get it to work, keep it running, and
thus reduce the cost of doing business. Today health information management is more about
improving the performance of professionals and staff in health care organisations. It entails
providing the right information to the right people, within and beyond the organisation, at the
right time and location, for the right price by effectively applying information technologies
through the application of effective change management techniques. It is the latter part of the
mandate that continues to be a major stumbling block for successful information management.
14. Investigate the appointment of integrated care case managers.
In today’s NHS, multiple professionals can deliver each episode of care. For example, a patient
goes to a GP, is referred to a diabetologist who orders various tests, interprets the tests, makes a

diagnosis, formulates a care plan, and updates the GP on the patient’s situation. Such activities
can take days or weeks, and constitute a workflow, i.e. a network of actions by professionals or
providers, linked in time.
Put in generic business terms, a pathway can be viewed as ‘The automation of a business process,
in whole or part, during which documents, information or tasks are passed from one participant
to another for action, according to a set of procedural rules.’ In order for them to progress
smoothly, someone has to manage the process. Today, this is typically an ad hoc process man-
aged by medical secretaries, various letters of referral, and the patient him/herself. Workflow
systems can support such processes, by executing agreed models of care, and reminding the
relevant parties of events to be performed. But who oversees all of this on behalf of the patient?
Are there people already in place in some parts of the country with the overall responsibility for
acting as the "guide" for the patient along the pathway? Do they encompass the role of case
managers in social care but also include health care services as well? How many patient visits to
GPs are due to social problems?
For some patients/clients - say a well-managed diabetic – case management might not be onerous.
But for others such as the confused single elderly, with multiple morbidities, the role of the case
manager would be critical. It is often assumed that the GP does this, but often the GP refers and
it's then in the hands of the hospital, unless the patient comes back and gets the GP to follow up.
These ‘pathway managers’ would need routine exception reporting out of the systems supporting
their pathway management role and only remove the case/pathway from their caseload when it
completes or there is a formal transfer to another professional. The pathway manager could be a
GP but doesn’t have to be, it might be a nurse, social worker, etc. It could perhaps even be a NHS
Direct nurse. In some cases, the patient might take responsibility themselves.

7. CONCLUSION
It would be time well spent to reflect on the complexity of health care (Plesk article). Across all
disciplines, at all levels, and throughout the world, health care is becoming more complex. Just thirty
years ago the typical general practitioner in the United Kingdom practiced from privately owned
premises with a minimum of support staff, subscribed to a single journal, phoned up a specialist
whenever he or she needed advice, and did around an hour's paperwork per week. The specialist
worked in a hospital, focused explicitly on a particular system of the body, was undisputed leader of
his or her "firm," and generally left administration to the administrators.
We used to go to the doctor when we felt ill to find out what was wrong with us and get some
medicine that would make us better. These days we are as likely to be there because the doctor (or the
nurse, the care coordinator, or even the computer) has sent for us. The evidence will now dictate our
treatment but this may well be imprecise, equivocal, or conflicting. Our declared values and
preferences may be used, formally or informally, in a shared management decision about our illness.
The solution to our problem is unlikely to come in a bottle and may well involve a multidisciplinary
team.
Not so long ago public health was the science of controlling infectious diseases by identifying the
"cause" (an alien organism) and taking steps to remove or contain it. Today's epidemics have fussier
boundaries (one is even known as "syndrome X"; they are the result of the interplay of genetic
predisposition, environmental context, and lifestyle choices.
Into this increasingly complex world we are trying to introduce information technology fully realising
that one cannot buy an EPR or an EHR off the shelf, as it is something that develops incrementally
over a number of years. Whilst, the EPR/EHR is not about technology but more about a long-term
cultural change programme, the technology can enable that cultural change to occur.
Much research has been done in an attempt to identify the key factors that predict EPR/EHR
implementation success (Sittig article). Over 150 factors have been identified, but only two, "top
management support" and "user involvement" are consistently associated with successful
implementations. Several additional key elements have been repeatedly identified:
• "Buy-in" of the organization is important. All users must clearly see the need for the change if
they are to support it.
• There must be a clear understanding that significant change occurs in multiple stages, and that
errors in any of the stages can have devastating consequences.
• Local champions must actively and enthusiastically promote the system, build support,
overcome resistance, and ensure that the system is actually installed and used.
• Finally, it must be recognized that it can take at least six months of EPR/EHR usage before
any decisions about the success of the technology introduction (particularly in terms of
individual worker productivity) can be made.
It is increasingly self-evident that change management and organizational development activities must
accompany the introduction of an electronic care record. While such capabilities may often be "ahead
of the organization", it must not be so far ahead of the process that it causes the organization to give
up before the journey is over. Therefore, a key requirement of senior leadership is to carefully
manage the trade-off between the healthy changes introduced by the electronic care record and the
increased risk that its implementation will fail because of those changes.

In a nutshell, it is people, not technology, that make the difference between success and failure.
When end users want to make IT tools work for them, even "poor" tools can deliver real business
value.
Failure to realise value is seldom due to a tool's need for changes but to a mindset that is not
motivated to work with the tool as it is. Configuring technology tools will requires changes in the way
we do things - by users and to business processes. Imagine a group of lumberjacks using chainsaws
the same way they did handsaws by sawing back and forth. They would certainly use the chainsaws
differently than handsaws, but they would not automatically know the best way to use the new tools.
IT tools are no different. When the tools change, the people and the business processes must adjust.
Business value increases when users are determined to work with the new tools, but the value
decreases when the users are not motivated.
Put another way, is f (D, V, S) > R? This is an expression of Gliecher’s “Change Equation”. It says
“In order for change to occur successfully, the combination of Dissatisfaction with the
present situation, a Vision of a more desirable future, and the knowledge of the first Steps
to take in moving towards that future, must be greater than the Resistance to, or costs of,
the change. If any of the first three factors are missing, then change will not take place
successfully, no matter how strong the other factors are.”
The challenge for the future NHS is to translate an increasingly greater knowledge of the relationship
between social, clinical and technical issues into effective patient-centered systems that operate across
transient organisational boundaries. This is the bad news – it is not an easy task. It is somewhat akin
to asking the horse and buggy drivers of years gone past whether they could foresee the need for
windshield wipers on the first motorised vehicles. It was only when they began to operate these new
vehicles in the rain did they become aware of the need for windshield wipers. Similarly, it takes time
to nurture and grow an EHR. Electronic records cannot be rushed and an overnight courier cannot
deliver them.
The good news is that there is strong and determined political commitment to reform the NHS and to
use Information Technology as a vehicle on which such reform will ride. If the Service and its
clinicians are equally committed, then watch out - the EHR journey will shift into high gear.

Appendix A
IPU WORK PLAN FOR DENIS PROTTI FOR AUGUST – SEPTEMBER 2001
Guiding statements
“In June 2001 the work of the demonstrator sites will be assessed with a view to making policy
statements by September 2001 in areas such as the development of the 24 hour emergency EHR,
standards for primary/community EPRs etc.”
BIC, Section 4.8
“The EHR will hold summarised key data about patients, such as name, address, NHS number,
registered GP and contact details, previous treatments, ongoing conditions, current medication,
allergies and the date of any next appointments. The EHR will be securely protected, created with
patient consent, with individual changes made only by authorised staff”.
“Over the next four years, every adult will be able to access their own at-a-glance `electronic health
record’.”
“The Electronic Health Record will help put patients in control. The sustained investment we are
making in NHS IT will help redesign the health service around the needs of its patients. In future,
every patient will have easier access to their own health records.”
Secretary of State
Department of Health Press Release 2001/62
Key questions to be answered
• How many ERDIP sites not making progress due to the lack of standards?
• What remains to be done to assure that the connectivity, linkages and compatibility of records
within the NHS including General Practice and Social Services?
Actions to be undertaken
1. Assess the work of the ERDIP demonstrator sites to flesh out the gaps in the IPU work
programme in meeting IfH targets - not just in the demonstrators but in primary community care
EPR.
2. Sift from ERDIP demonstrators what standards (perhaps currently only at a local level) may be
emerging that look promising
• Consider technical and clinical standards that underpin LIS to support NSF
• e.g. general standards need to be adopted as identified in Mental Health Information
System (Appendix 2 – generic and clinical standards)
• Recognise emerging international standards (e.g. HL-7, XML, etc.) and government
standards (e.g. e-gif)
3. Take into account:
• Interoperability issues (e.g. electronic datasets being developed and care pathway
developments)
• How the information agenda is and should be addressing the direction set out in NHS
Plan and the emerging NSFs.

• The organisations (e.g. NHS Direct, Primary Care division, etc.), programmes, and
timetables influencing the information agenda such as:
• Population Records
• Booked Admissions
• Etc.
• The more holistic view of supporting the emerging integrated care model including PCTs,
the new care trusts and social care
4. Recommend which topics could do with policy statements (as opposed to a guidance or status
report) by September 2001 in areas such as:
• The 24 hour emergency care EHR
• Standards for primary/community EPRs
• Etc.
5. Suggest approaches for how the above statements could be disseminated (e.g. Update web site)
6. Take it as given that the primary priority in terms of the Emergency EHR is the tool to assist in
the day-to-day delivery of care as opposed to the data to support clinical governance,
epidemiology and retrospective analysis.
7. Deliver a report by 12 September 2001 that identifies the issues and suggested means of
addressing them.
Methods to be used
1. Liaise with Malcolm, Anne Fletcher, Paul Jenkins, NHSIA, etc.

2. Review ERDIP demonstrator site reports – including those that may not be on the Information
Authority web site.
3. Review key government publications such as:
• Data Protection Act
• Information for Social Care
• Managed Clinical Networks
• Shifting the balance of power
• Etc.
4. Review internal IPU and NHSIA documents and minutes such as:
• EHR SOC
• Feedback to the EHR SOC
• Primary Care Information Management Board minutes
• Etc.
5. Follow-up by phone with anyone as need be.

Appendix B
NHSIA WORK PLAN FOR DENIS PROTTI FOR AUGUST – SEPTEMBER 2001
Guiding statements
• The goal of NHS Plan is a health service designated around the patient. A major need is thus
support for integrated care across the organisational boundaries of the NHS.
• The NHS has clinical priorities.
• Primary care may be a restrictive term; fully integrated care (including social services) may better
capture the intent of the emerging model of health care delivery.
Remit
From the perspective of the NHSIA and the wider Information for Health community, the consultancy
will:
1. Examine how information support is to be provided given current initiatives.

2. Identify opportunities for better alignment of efforts and/or gaps in existing efforts.
3. Examine the state of ‘primary care’ services and its information needs with a focus on:
• Innovation in health services
• Patient-centered approaches
• Patient involvement
• The development of patient-based records and patient access to those records
4. Examine NHS Direct and how the NHSIA can better integrate with that development.
Actions to be undertaken
1. Review relevant background documents such as:

• Data Protection Act
• Information for Social Care
• Managed Clinical Networks
• Shifting the Balance of Power
• Why Wait?
• Etc.
2. Document current health care and information initiatives and how they fit together.
3. Document apparent gaps and/or barriers in current information offerings.
4. Document current (and emerging) issues pertaining to person-based record systems and
approaches in the NHS (e.g. Hadfield) and elsewhere (e.g. Wellmed).
5. Arrange to visit selected Primary Care Trusts to discuss information strategies
6. Review relevant NHS Direct documents.
7. Liaise with NHS Direct officials as need be.
8. Deliver a report by 20 October 2001 that identifies how the NHSIA can best engage and support
the above mentioned developments.

Appendix C
PEOPLE INTERVIEWED
Department of Health NHS Information Authority
Anne Fletcher IPU Anthony Nowlan

David Colin-Thome DOH Charles West
David Young IPU Colin Price
Francis Martin NWRO Gwyn Thomas
Lesley Hannam NWRO Ian Soaby
Malcolm Pearce IPU Marlene Winfield
Nick Hicks DOH Nigel Bell
Peter Drury IPU Peter Nicklin
Sir John Pattison DOH Steve Walker
Trevor Dyson IPU
Scottish Health Service
National Health Service
Alan Hyslop Scottish Health Executive
Alan Spours Stafford NHS Trust Charlie Knox Scottish Health Executive
Andrew Haw Birmingham HA Lesley Paterson Highland Hospital Trust
Caroline Rae Morecambe PCT Mike Lister Highland Hospital Trust
Cecilia Pyper Bury Knowle Medical
Dallas Ariotti Birmingham HA Others
David Gakell Fortrose Medical
Doug Scott South Humber HA Alasdair Liddell iMPOWER
Frank Burns Wirral NHS Trust Elaine Mundy King’s Fund
Ian Roberts Bradford HA Ian Smith SECTA
Janet Walker Scunthorpe Hospital John Farenden SECTA
Mary Taylor Fortrose Medical Nick Nicholson York University
Nicholas Oughtibridge Scunthorpe Hospital Roger Dewhurst SECTA
Paul Charnley Wirral HI Services Tom Brooks PITCOM
Peter Gentle Chair, ERDIP Board Victor Peel B-Plan
Richard Fitton Hadfield Medical
Roy Evans South Staffs HA
Tony Megaw Bradford HA
Wally Gowing South Staffs HA
NHS DIRECT
Eileen Carney-Jones
Hazel Penny
Jane Coster
Nick Robinson
Paul Jenkins

Appendix D
DOCUMENTS READ AND/OR REVIEWED
• Audit Commission; Life in the Fast Lane: A Value for Money in Emergency Ambulance Services;
September 1998
• Beale T; Health Information System Manifesto; ISO TC216: 2001
• Bojke, C. et al; Is Bigger Better for Primary Care Groups and Trusts?; University of York; February 2001
• Campbell, S.M. et al; Identifying Predictors of High Quality Care in English General Practice:
Observational Study; BMJ; October 2001
• Canter, R.; Patients and Medical Power; BMJ; August 2001
• Deyo, R.; A Key Medical Decision Maker: The Pati ent; BMJ; September 2001
• DOH; Building the Information Core; July 2001
• DOH; Information Implications of Shifting the Balance of Power, May 2001
• DOH; Information Systems to Support Integrated Primary, Community and Social Car; May 2001
• DOH; Investing In Primary Care; August, 2001
• DOH; Managed Clinical Networks; September 2000
• DOH; National Infrastructure Services for the NHS; March 2001
• DOH; National Service Framework for Coronary Heart Disease; October 2001
• DOH; NHS Performance Ratings; Acute Trusts 2000/01
• DOH; Population Records; Strategic Outline Case; July 2001
• DOH; The NHS Cancer Plan; August 2001
• DOH; The Single Assessment Process; August 2001
• ERDIP; Bradford; Focused Demonstrator Site for the Emergency Electronic Health Record; July 2001
• ERDIP; Bradford; Smart Cards and the Electronic Health Record; March 2001
• ERDIP; Bury Knowle Health Centre Final Evaluation Report; October 2001
• ERDIP; Cornwall; GP System (Microtest) and Clinical Care Integration; February 2001
• ERDIP; Durham/Darlington; Ethical Framework for the Electronic Health Record; April 2001
• ERDIP; Durham/Darlington; Reference Configurations for Electronic Health Records; April 2001
• ERDIP; Gloucestershire; Benefits Realisation and Evaluation Plan; December 2000
• ERDIP; NHS Information Authority; Minutes of Programme Board Meeting; July 2001
• ERDIP; North and Mid Hampshire; Data Standards; January 2001
• ERDIP; North and Mid Hampshire; Technical Specification; January 2001
• ERDIP; North and Mid Hampshire; Technical Standards; February 2001
• ERDIP; Personal Access to Online Health Records; March, 2001
• ERDIP; South and West Devon; Initial Evaluation of Patient Interaction with the Electronic Health Record;
March 2001
• ERDIP; South Staffordshire; EHR Evaluation Framework; September 2000
• ERDIP; South Staffordshire; EHR Information Requirements and Data Capture Issues; January 2001
• ERDIP; South Staffordshire; Emerging Models of Emergency Care; July 2001
• ERDIP; South Staffordshire; Information Standards for South Staffordshire Electronic Health Record;
January 2001
• ERDIP; South Staffordshire; Local and National EHR Implementation Issues; February 2001
• ERDIP; Tees; Initial Findings of the Consent and Confidentiality Project; March 2001
• ERDIP; Tees; Initial Findings of the Data Sharing Project; March 22001
• ERDIP; Tees; Initial Findings of the EPR/EHR Project; March 2001
• ERDIP; Walsall; Enterprise Master Patient Index
• Eversheds; Electronic Health Records; July 2001
• Fairey M; editorial, BJHC; May 2001
• Fitton, R; Electronic Health Records Strengthen the Doctor Patient Partnership; Guidelines in Practice;
June, 2001

• Gottlieb S; Drug effects blamed for fifth of hospital deaths among elderly; BMJ; November 2001
• Hassey A et al; A Survey of Validity and Utility of Electronic Patient Records in a General Practice; BMJ;
September, 2001
• Hayes GM, Thornton MH; Open source software for health – threat or promise; p. 153, HC 2001
Proceedings
• Knight M; The effective use of e-mail; p. 209; Healthcare Computing 2001
• Kravits et al; Engaging Patients in Medical Decision Making; BMJ; September, 2001
• Lambeth Southwark & Lewisham Health & Social Care Community; Moving Forward With Primary Care
IM&T: Strategic Outline Case; March 2001
• Leapfrog Group; Computer Physician Order Entry (CPOE) Fact Sheet; http://www.leapfroggroup.org/;
November 2000
• Muir, S. et al; Patient Access to Electronic Patient Records at the Hadfield Medical Centre; Manchester
School of Management; April, 2001
• Munro J. et al; Impact of NHS Direct on Demand for Immediate Care; Observational Study; BM; July 2000
• NHS; Definition of Modules Making Up EPR Level 3; April, 2001
• NHS; Electronic Health Record; Strategic Outline Case; July, 2001
• NHS; GP Clinical System Supplier Market Review; July, 2001
• NHS Direct; A New Gateway to Healthcare
• NHS Direct; Evaluation of NHS Direct first wave sites: Final Report of the Phase 1 Research; July 2001
• NHS Direct; NHS CAS and the Development of the Emergency Health Care Record; August 2001
• NHS Direct; Raising Standards for Patients New Partnerships in Out-of-Hours Care; October 2000
• NHS Information Authority; Clinical Messaging Programme; March 2001
• NHS Information Authority; Implementing National Standard Pathology Reports Messaging; September
2001
• Norris, A.C. et al; Care Pathways and the Information for Health Strategy; September 2001
• Plesk P and Greenhalgh T; The challenge of complexity in health care; BMJ; September 2001
• Rigby, M et al; Verifying Quality and Safety in Health Informatics Services; BMJ; September 2001
• Rigby, M. et al; Integrated Record Keeping as an Essential Aspect of a Primary Care Led Health Service;
BMJ; September, 2001
• Sittig D; The Importance of Leadership in the Clinical Information System Implementation Process;
November 2001
• Smith R.; Why Are Doctors So Unhappy?; BMJ; May 2001
• Thorp, J. M.; Information Implications of “Shifting Balance of Power”; August, 2001
• Vass London A; Councils must start work on new NHS scrutiny role; BMJ; November 2001
• Walshe K, Smith J; NHS reorganisation: Cause and Effect; HSJ, 11 October 2001
• Wilkin D. et al; The National Tracker Survey of Primary Care Groups and Trusts 2000/2001 - Modernising
the NHS?; National Primary Care Research and Development Centre

Appendix E
NATIONAL EHR-RELATED INITIATIVES (HEALTH ONLY)
1. Child Health Systems • Cancer Information Strategy

2. Clinical Audit Datasets Project • CHD Information Strategy
• 24 hour emergency EHR Dataset • HIP for CHD; MINAP
• Cancer Dataset • RCAPC Information System
• Central Cardiac Audit Dataset (CCAD) • Mental Health Information Strategy
• Mental Health Minimum Dataset • Older Peoples Information Strategy
3. Clinical Headings Project 35. NSTS
4. Clinical Messaging Project 36. PACT
5. Clinical Products Reference Source (CPRS) 37. Pathology Messaging Implementation Project
6. Clinical Terms (SNOMED CT) Project (PMIP)
7. Commissioning Datasets 38. Population Records (Registers)
8. Context of Care Project 39. Primary Care Drug Dictionary (PCDD)
9. Disease Registers 40. PRIMIS
10. DoH RDD funded projects 41. PRODIGY
11. EHR Strategic Outline Case 42. PROFESS
12. Electronic Bookings Project 43. Project Connect
13. Electronic Record Demonstrators (ERDIP) 44. Standards Boards
14. Electronic Transcription of Prescriptions
(ETP) Project
15. EPRs (Acute, Primary care, Community
Health, Mental Health, Social care)
16. ERTAG
17. GP Systems Computing (RFA99, RFA2001)
18. GP to GP messaging (record transfer)
19. Integrated Mental Health Electronic Record
(IMHER) Strategy
20. Local Implementation Strategies (LIS)
21. MIQUEST
22. MISB (formerly CRIR)
23. National Clinical Audit Support Program
(NCASP)
24. National Dental Information Strategy
25. National Electronic Library for Health
(NeLH)
26. Nation-wide clearing service (NWCS)
• Hospital Episode Statistics
27. NHAIS (Exeter)
28. NHS Data Dictionary and Data Manual
29. NHS Direct and NHS Direct on-line
30. NHS Messaging Service
31. NHS.UK
32. NHSCR
33. NHSnet
34. NSF Information Strategies

Appendix F
EARLY FINDINGS FROM ERDIP REPORTS
Issue Site Specifics
Alerts Cornwall The system should contain different levels of alerts. It should have Mental
Health, behavior or situation risks and generic issues. It should have the
facility to input information about patients who are at risk or who pose a
risk to others, e.g. abusive or violent patients. Dates of validity and expiry
are also needed.
South Staffs There is a need to develop a consistency of definition of ‘alert’ and
‘allergies’ and the medico-legal implications of recording them.
Authentication Bradford Patient identity issues (“Is the patient who they say they are?”) – especially
for non-patient facing interaction.
North & Mid There are also issues about whether the patient is who they say they are
Hampshire with respect to receiving treatment. This is particularly relevant in the
context of NHS Direct and Walk-in Centres. In our demonstrator we are
very concerned about the risk that a patient calls NHS Direct for help but
gives someone else’s name and address so that they can remain
anonymous. That could result in a feed from NHS Direct to the EHR
against the wrong patient.
North & Mid Our experience in the Hampshire NHS Direct is that the proportion of
Hampshire patients identifying themselves sufficiently well to do a NHS number
match is relatively small, typically 10-15%.
Balance Bradford A balance needs to be struck between the ultimate choice of the patient to
share information and the need for information by those treating the patient
(including staff safety).
Durham There is an inevitable balance to be struck between security on the one
hand, and flexibility and ease of use on the other. An EHR system that
protects each and every item of data by type of patient and by the level of
access accorded to each user is virtually certain to deny legitimate access
(in the sense that a user has good cause to be accessing a record) to at least
some users.
Consent & Access Bradford Wider debate by the public is required to enhance the quality of informed
consent in the EHR environment.
Bradford The prospect of data-field-specific access limitation should spur all EPR
system suppliers to affix access control attributes to every recorded item as
soon as possible.
Cornwall Patients must have a right to see and correct their own details. All
information referring to a third party must be removed. Also, there are legal
issues with regard to communication with 3rd parties (including solicitors).
Patients have the right to flag up disagreement with the opinion of the
clinician.
Cornwall There is a risk that patient consent will not be given or is limited to
particular data and certain staff.
Cornwall GPs currently control access to the data. When the information is shared on
the EHR this control mechanism will not exist.
North & Mid Guidance will be needed about how this demonstrator deals with the issue
Hampshire of patient consent, in particular, whether and how we should deal with
explicit consent.
South Staffs There is a need to clarify confidentiality and security issues, including the
option to ‘opt out’ of the EHR.
P AGE 62
S&W Devon Should a patient know if there is data withheld from them?
Should a patient see data before explained to them by a physician?
How best should bad news be broken to patients in the context of access to
the EHR?
Cryptography S&W Devon Without encryption the EHR will be untenable. Not only are digital
signatures based on cryptographic techniques, but also secure
communication, authentication of users and storage of data relies upon
encryption. For patients to be confident in the security of their records, they
must also be confident in the integrity of the trusted third party and in the
strength of the encryption process.
Data Coding Bradford Data standards are required to ensure consistency; coding processes should
not detract, however, from the richness of narrative record keeping.
Cornwall Need to agree standard coding system. READ 2 terms are used in GP
systems. READ 3 terming are used on the EHR, and SNOMED will be
introduced within the next fourteen months as the new national standard.
Headings Gloucester The staff felt the Headings were not intuitive and that the definition
describing the information to be provided under each Heading was
ambiguous in some cases. The subsequent audit highlights that incorrect
information was recorded under certain Headings and that information was
sometimes combined which should have been recorded under separate
Headings.
Interfacing Gloucester The concept and definition of items between systems is not a common one
and they have different attributes (even though two items may be referred
to by the same name). The focus within one system is almost wholly on
cost, while the other concentrates on and contains additional elements of
care, proceeding to much lower levels of data collection/definition. While
former system can work on the level of an order, it has difficulty coping
with the underlying tasks, forms and catalogue items.
Wirral Given the fact that there are a number of different systems that need to be
considered for inclusion into the EHR, the core administrative and
demographic data items are fairly standard across those organisations,
which should help in the consolidation, phase. One data item, however, that
is not collected as a standard is surname at birth which can be another item
for discussion, but initial thoughts would point to it being collected in
primary care.
Master Patient Bradford Fundamental to the model of the EHR provision in this context is the
Index deployment of a master patient index (MPI) to provide the infrastructure for
the clinical information. The MPI requires maintenance to ensure that the
usefulness of the demographic data.
North & Mid The EHR will require a consolidated Patient Master Index. This will be
Hampshire primarily indexed using the NHS number. It will also include reference
keys that will allow reference to records in the feeder systems. Several data
matching issues need to be resolved. These include matching records
between the WEHT HIS, Social Services, GP systems, etc to verify that the
records that currently reside on these systems actually relate to the correct
patients, e.g. Social Services records are keyed on a unique identifying
code that is not related to the patients’ NHS number.
Walsall The enterprise MPI must ensure that the natural communities disparate
MPIs are merged together with the availability of ongoing processes to
enable data quality checks, merging of records and links to the national
strategic tracing service. The natural community has a variety of systems
meeting the needs of specific health organisations and departments:
community visitors, midwives, social services, and pathology, PAS etc.
P AGE 63
Provenance North & Mid The EHR should hold flags that identify where a particular patient/client
Hampshire record has come from. It will also need a structure of flags to identify
issues about patient consent.
South Staffs Understanding the provenance of information in the EHR is crucial -
without provenance information the clinical data in EHR will be
undependable.
Tees How will information be maintained and will each entry be tagged with
who entered it and when?
Sharing Cornwall The system must have controlled sharing of information, subject to
different levels of access. Information must be clearly sign-posted.
Recipients must be able to select only what they need to know, subject to
permissions and access levels.
Cornwall There is a requirement for the facility to block the sharing of data items at
the request of the patient or clinician in addition to the normal system
security. This has consequences of an incomplete record.
North & Mid There is currently no national agreement on a standard approach, format,
Hampshire adoption of common procedures or documentation for the development of
information sharing protocols, although there has been significant amounts
of work undertaken by numerous parties.
P AGE 64
Appendix G
ERDIP REPORTS AVAILABLE ON THE NHSIA WEB SITE

AS OF SEPTEMBER 12, 2001
Site Reports written

since Nov. 2000
Suffolk 13
Cornwall 12
Walsall 11
North & Mid Hants 9
South Staffordshire 7
Wirral 6
Gloucester 5
County Durham & Darlington 4
Tees 4
Kingston & Richmond 4
Bradford 3
West Surrey 2
Hillingdon 1
South & West Devon 1
Camden & Islington 0
Dorset 0
Merton, Sutton & Wandsworth 0
----
82
P AGE 65
Appendix H
SELECTED COMMENTS FROM RESPONDENTS TO THE EHR SOC
1. The SOC makes a clear case for a national EHR solution that is based upon existing elements of
national infrastructure. However, although there are a number of references to ERDIP throughout
the document, the ERDIP Programme does not appear to feature strongly in the thinking in the
SOC or the direction proposed. The assumption is that a national EHR will be fed directly by
appropriate EPR feeder systems. If this is the case, it is unclear how the development of
community-wide solutions will contribute towards or link with the national solution.
2. Emergency care must be regarded as a specialised context of EHR use. If this context is to form
the focus of the first generation national EHR, the design will need to ensure that the
characteristics of emergency care are not inscribed in the system in such a way that it precludes
the longer term requirement for a life-long record. Should not the outcomes of the demonstrators
be used in the design and development of a national EHR to ensure that subsequent generations of
the national EHR solution are fully aligned with local developments?
3. The Exeter system is an existing example of a national system implemented at local level. Should
work not be done to identify if Exeter, with modifications, could provide some of the functionality
required to support the emergency care EHR, providing the “bridge” between local / health
community EHRs and a national EHR application / portal? Open Exeter facilities already provide
some links into the Exeter population data by Trusts and GPs.
4. Some may argue that there is a grave misunderstanding in EHR development. They will argue
that clinicians need detail. Whether an orthopedic surgeon seeing an outpatient, or an elderly
person awaiting discharge from hospital. The detail and granularity of the primary care EPR will
need to be accessed to help inform the decision-making. Removing the EHR to a sterile updated
note and then repository will reduce the benefit. The boxes will be ticked but the product will be
flawed.
5. The definition of emergency/urgent care seems to miss the associated objective of out of hours
care. Emergency care, and presumably urgent care, is characterised by incidents where time is of
the essence. In these cases only very limited amounts of information can help because the staff
would not have the time to delve deeply. Out of hours overlaps with emergency care but is not
always so pressed for time. It could be someone calling out a GP over night or a referral from the
A&E department to a specialist elsewhere in the hospital. These are the cases where a bit more
detail in the EHR could provide valuable information. They are the cases where the clinician
could potentially have a little bit more time and the need to consider past history and recent
events. Surely the first generation EHR will be important to these people as well.
6. It was disappointing to see the staff in mental health and social care excluded from this first
generation record. For a start, social care provides a whole new range of useful information about
identifying patients that will be extremely useful for emergency care. In particular, social services
tend to hold much more information about aliases and about next of kin and carers than we hold
in the NHS. In an emergency, knowledge of aliases, particularly if partners or friends are using
that other name, might make the difference in actually getting to the right EHR record.
P AGE 66
7. Working on a primary care EPR requires health communities to face up to their legacy of stand-
alone GP practice systems. Ideas that the primary care EPR can be built as a data repository
culling information from between 50 and 150 separately managed GP practice systems is sheer
pie in the sky. Clinically, it is impossible to determine whether what the repository contains is the
latest piece of information. Radical new approaches are required. In essence, however, the SOC
undertakes a sleight of hand: by ignoring the IfH approach, the problem of 9,000 practice systems
nationally can be made to disappear. In reality, it hasn’t: building the national emergency EHR
still requires health communities to cull information from all these independent systems. This lays
a huge risk on local communities.
8. The SOC does not seem to fully acknowledge that the data that makes up the EHR is generated
from the existing GP systems or Acute Trust systems. The EHR does not appear to them to be a
separate system or application isolated from these existing operational systems. The EHR has to
be built out of the data provided by these systems. Some of these systems are available 24x7 and
therefore could be queried anytime to provide the data needed to populate or refresh the content of
an EHR. Many of these systems (typically the GP systems) are not available 24x7 and therefore
an approach that would enable summary data to be copied into an EHR would seem to be
appropriate. How will the provision of a separate EHR system work unless one is prepared to
leave out all of the existing information - or to have data and data-entry duplication between the
EHR system and existing operational systems.
9. There are a significant number of hidden costs associated with constructing an EHR from feeder
systems that go beyond supplier solutions. For example, there will be considerable cost impacts
associated with data integration, data management and patient consent that are outside the
boundary of the supplier solutions. There will also be additional costs associated with the
network, security management, change management and so on. In addition, if the feeder system
data is in an inadequate format this will impact the ability to aggregate, report on and manage the
data for the purposes of an EHR. The costs of rectification will need to be taken into account – for
example if key/critical data elements in feeder systems are in free text then this data must be re-
entered in a format that enables data management and reporting for the purposes of the EHR.
P AGE 67
Appendix I
THE 8 WS:
THE MINIMUM DATA ELEMENTS OF A HEALTH CARE ENCOUNTER (TRANSACTION)
Data element Standard
Who Patient/Client Personal Health Number NHS #
went to Whom Provider Provider Unique Number PUN
Where Site-of Care Site-of-Care Unique Number SUN
for What Diagnoses/Problems Provider view of “Reason for Encounter” ICD-10
for What Intervention/Encounter Classification of Interventions OPCS 4

(Procedures)
When Date & Time yr/mon/day/hr/min/sec
at What Cost Unit cost of resources used ££
and What Happened (Outcome) Functional /Health Status/State of well- SF 26

being
NB: Nomenclature systems such as SMOMED CT will eventually be used by providers to capture greater
clinical detail (including modifiers and semantic links) for Diagnoses/Problems, Intervention/Encounters, and
Observations. These systems will automatically generate ICD-10 and intervention (procedure) codes for
statistical, management, and research purposes.
P AGE 68
Appendix J
THE EVENTS EHR: A QUICK WIN ON THE EMERGENCY EHR AND POTENTIALLY MUCH MORE
National Databases Outputs

Patients
Providers
Certificate Authority
NHS Staff (Access Management)
0 Client demographics
PCTs Web-enabled NHSCR GP details
Browser via Encrypted Portal Immunisation data
Trusts Internet or Reliable Broker NWCS Screening data
NHSnet Responsive (CORBA/ 1 Medication data
DCOM)
StHAs ------------ Redundant PPA
XML Client Registry (NSTS) 2 Referral data
Pharmacies interfaces Care Provider Registry Others (e.g. diseases) 3 Inpatient events
Site registry 4 Outpatient events
OOH Products Dictionary Exeter 5 Booked admissions
Drug Dictionary 6 A&E events
NHS Direct 7 NHS Direct events
Data Validation 8 Social care events
PPA Anonymisation Etc.
Authentication
Others DSS (e.g. PRODIGY)
SNOMED CT
Guidelines
NSF Generic Pathways
Etc.
P AGE 69

Implementing Information For Health: Even More Challenging Than Expected?

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Implementing Information For Health: Even More Challenging Than Expected?

Uploaded by

Copyright:

Available Formats

Implementing Information For Health: Even More Challenging Than Expected?

EVEN MORE CHALLENGING THAN

Submitted To: Dr. Peter Drury

Dr. Gwyn Thomas

Submitted By: Professor Denis Protti

Date: 11 June 2002

FINAL COPY 11-J U N -02 P AGE 1

2.1 Introduction …………………………………………………………………………… 12

3 ENVIRONMENTAL SCAN .............................................................................................. 14

3.1 Government Policies and Direction ................................................................................. 14

4 INFORMATION FOR HEALTH ..................................................................................... 20

4.1 Introduction …………………………………………………………………….……… 20

6.1. Harmonise the many performance management targets ….………………………….. 37

FINAL COPY 11-J U N -02 P AGE 2

FINAL COPY 11-J U N -02 P AGE 3

FINAL COPY 11-J U N -02 P AGE 4

Information for Health

Delivering the Infrastructure

FINAL COPY 11-J U N -02 P AGE 5

Initiatives and targets

FINAL COPY 11-J U N -02 P AGE 6

The consent issue

FINAL COPY 11-J U N -02 P AGE 7

I find it difficult to provide explicit guidance to the primary/community (non-hospital) sector in

FINAL COPY 11-J U N -02 P AGE 8

FINAL COPY 11-J U N -02 P AGE 9

Knowledge and learning

FINAL COPY 11-J U N -02 P AGE 10

FINAL COPY 11-J U N -02 P AGE 11

FINAL COPY 11-J U N -02 P AGE 12

2.2 Acknowledgements and Apologies

FINAL COPY 11-J U N -02 P AGE 13

3.1 Government Policies and Direction

• Department of Health reorganisation, including the integration of the Modernisation Agency

The political expectations seem to be quite clear:

FINAL COPY 11-J U N -02 P AGE 14

3.2 Service Response and Reaction

• The NHS Plan is only 15 months old

FINAL COPY 11-J U N -02 P AGE 15

FINAL COPY 11-J U N -02 P AGE 16

3.3 NHS Direct

FINAL COPY 11-J U N -02 P AGE 17

FINAL COPY 11-J U N -02 P AGE 18

FINAL COPY 11-J U N -02 P AGE 19

4. INFORMATION FOR HEALTH

Care Direct National Service Frameworks (NSF)

FINAL COPY 11-J U N -02 P AGE 20

4.2 Political Expectations and Pressures

FINAL COPY 11-J U N -02 P AGE 21

FINAL COPY 11-J U N -02 P AGE 22

It is the envy of many countries that by 13 September 2001, England had:

• 8469 (97%) practices with an NHSnet line installed

• The Local Implementation Strategy (LIS) process – a mechanism to bring together

FINAL COPY 11-J U N -02 P AGE 23

• A more reliable and robust NHSnet

FINAL COPY 11-J U N -02 P AGE 24

4.4 General Observations

FINAL COPY 11-J U N -02 P AGE 25

FINAL COPY 11-J U N -02 P AGE 26

So many questions, so few answers.

FINAL COPY 11-J U N -02 P AGE 27

• The emphasis on star ratings

FINAL COPY 11-J U N -02 P AGE 28