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GP Systems of Choice
Connecting For Health: original essays
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NHS Organisations impacting Primary Care
Practice Based Commissioning
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NHS Connecting for Health: The World's Largest IT project
  • Changes, improvements, in CfH thinking is bests shown by the development of GP Systems of Choice
  • The original articles on Connecting for Health and further background is here 

In 2007 further developments and more pragmatic approach is developing. Parliamentary Health Committee is considering progress to date (click to link)

CfH, Connecting for Health, pushed the following themes:

1.  It is essential that there is a single NHS record, so health workers can use a common system: The need for a single global healthcare record is a statement of fact that cannot be challenged.

2.  Patients already assume we share such data and are disappointed to know that we do not.

3.  Up to 80% of computerised records are lost between practices. 

Of the "lost record" argument, there is the GP2GP system coming up, a programme that was started before Connecting for Health, and it will transfer the electronic records between practices.  Currently printed out paper backups do go into the paper notes, while practices manually edit (cull) the records for the important facts, and any readcoded items such as "had chat to patient" left out, to avoid clutter. So "lost" is not quite the word, and who says it is a bad thing to do so?  Culled and edited is more the point.  There will not be any culling and editing of the NHS record, although there may be "sealed envelopes" for patients confidential material.

Information Anywhere for Clinicians:  Is that always a good thing?
Connecting For Heath trumpets the idea is that if you attend a hospital or a G.P. elsewhere, the doctors and nurses would have access to a single summary care record.   We have done without such access for aeons. A telephone call the next day irons out any real difficulties about a patient's history.  It seems obvious at first sight, that if you enter casualty staggering about the place, that the hospital doctors should be able to see your clinical records of your G.P. and the records of any other hospital you have attended.  Surely would save time and effort for the team to be able to read, from anywhere in the UK your old records?  That is in fact a risky thing to do.

Doctors, on seeing a new ill patients must start afresh, take a history and examine the patient.  There are  risks in relying on previous diagnoses and computer entries. To do so would make us lazy, and closes open minds.  One day a patients staggers into casualty with slurred speech.  The casualty doctor would, it is hoped,  read on the Integrated Care Record that the patient has an alcohol problem, according to the (teetotal) G.P.'s clinical record. Assured by that, the casualty doctor parks the patient in a corner to sober up.  Alas the patient was staggering about because he had a small stroke, or that he had cerebellar problems from undiagnosed low thyroid levels, or was even developing meningitis.

"Mistaken Identity" was a conference at LSE 19th May 1994.  We heard from Paul Whitehouse, the former Chief of Constabulary of Sussex, an example of how IT can get in the way of thinking on your feet, an essential clinical skill, which INCREASES risk.    My summation was thus: 

Before "IT"  a constable would have to think on his feet. A PC stops a car acting oddly, such as going through a red light.  The constable had no access to any data systems.  He asked the passengers and drivers a few questions, and then, whilst keeping them seated, the PC opens the boot.  Should the passengers not have mentioned, nor explained the fishing rod in the boot, it would suggest the car was not theirs.   In Spain a few years ago a car was stopped, but  thanks to modern IT the car registration could have been checked before the car had even come to a halt; it was not stolen, it was a hired car, a fact confirmed by the passengers and driver.  The driver's and passengers'  ID cards could be checked on the spot, and all checked out on the central computer; none of them was a wanted man.  The car is allowed to go on; the police comforted by the IT data.  It was a shame that they did not look in the boot, as that contained the Semtex that blew up the trains in Madrid. 

I now see that my memory of his telling of it I now see is not quite accurate.  I found the whole speech is here.

In medicine we are dealing with biological, and fast changing systems.  We need to start again when we see patients, especially in an emergency, and NOT be biased by what was written before.  All working to the same record may have benefits, but also huge risks ESPECIALLY, in the emergency situation.   Nobody in Connecting for Health sees that. There benefits to the this clinical intervention and there are risk as well, like any medicine, drug or procedure. Global access to records is seen as always as good thing, but there is no clinical trail to prove that.  It is an assumption.

It would be nice, for starters, that there was a single accessible record WITHIN each hospital or institution.

The recording of Allergies: An example of the complexity of the task.
It also seems obvious  that a hospital doctor should know, from anywhere in the country, that a patient is allergic to a drug.   But that simple idea turns out to be a complex task.  What is allergy?  It could just be a rash when once when given penicillin as a child. But that rash may have been due to the viral infection at the time. Collapse and anaphalaxis... that's what I mean by allergy.  Or do we mean intolerance...such as upset stomach with an antibiotic such as erythromycin.   But in a life saving situation one would not like to avoid using a drug just because the patient did not like the colour or the tablets and was vaguely coded as "allergic" to it on a previous occasion.  How we record allergies and what we mean by them is complex.  For a G.P. using his computer, in his surgery, allergy recording is a method to get his clinical system to help the surgery team avoid upsetting the patient again by giving medicine X.  For a hospital doctor that same information will have to be taken as an injunction NOT to give the drug under any circumstances, as they would assume that there is a high risk of collapse or death if the patient was given the drug.   Data on G.P. computer systems were collected for use within the surgery.  To use this data for a different purpose, that is creating a National data set to be used by others without knowledge of the patient, adds an astonishing level of complexity of the task.

Incorrect entries
The next problem about  a summary national record is the question just who has the "root" permission to delete an incorrect entry?  The answer is nobody at all can do that.   What must be done add another line to state the line above, or referring to the one of many lines above was wrong.   A patient wrongly diagnosed as allergic to penicillin has to have another entry to say the opposite. Currently the Read coding system does not cater for this. Negatives, incorrect entries are deleted.  The is no "NOT" code.  I am not sure how negatives are to be put on the system at all.    Some practices used to put in codes such as H33 asthma and then in free text adding excluded.  Well of course the systems pick up the code as asthma, the patient has asthma.  There is no code !H33 meaning NOT asthma.  On G.P. clinical system we can delete the entry (there is an audit trail to say one did so) but the NHS care record will not allow that to occur.  I am still not sure how this has been resolved. SNOMED, a new coding system may have a negation function.

Run before we can walk.  The first thing is to have electronic records within each institution working properly. The Connecting for Health team dismiss the bits of NHS IT that work as "Digital Islands of Care".   G.P.s account for over 80% of NHS care, and ALL G.P.s computer systems on their desks.  We use them very effectively, as G.P.s have recently demonstrated with high quality of care scores (QOF). That QOF data was uploaded centrally automatically from our "legacy" systems.  The G.P. "digital island" they refer to, is a vast continent, representing the largest clinical usage in the world.   Only now is it being admitted by the Connecting for Health teams that General practice remains aeons ahead of the rest of the service, and that the Connecting for Health should not destroy that which is working well.   Even now there are some excellent accredited G.P. system suppliers that do not have a home on Connecting for Health's Local Service Providers, and could not be used by G.P.s.  G.Ps still do not have a full choice of system.

Still many hospital and community practitioners are not using clinical systems, and consultants in hospital use and losing paper records.  Communications within hospitals are not there yet.

Common User Interface Across NHS.
This seems a good idea.  With the NHS having a huge staff turnover, and as staff moving hospital, it seems reasonable to have a common look and feel to the NHS systems from wherever you are. It would reduce training costs.  However G.P. have very low turnover, seldom move surgeries, and their staff are loyal.  There is a training component to get used to idiosyncratic G.P. clinical systems, the speed at which the staff can operate one that is done, is faster than on systems that do not require training to use.

The interface to systems is the most complex part of software.  It determines the speed of operation.  What SELLS a product is the speed at which users can believe they are using it.  That leads to the use of mice and drop down menus....but for busy clinicians those interfaces are no good.  We must keep eye contact with the patient, not look at where the mouse is pointing.

The NHS Common User Interface has two components. It is based on XP and the latest version of Office, the latter will be tweaked to have medical term checking and medical spell checker. Other NHS functions my be in-built.

The next is to have a framework on which a common interface for all the hospital and clinical systems can use.  The risk of that strategy is that it will set the NHS IT in aspic.  There will be no new interface designs possible.   No new ideas will be able to bubble up from the bottom.

Will the Connecting For Health programme be swept away by outside change in technology?   It would only take the likes of google to invent a medical care record service and that would be that!

Choose and Book
This was a good idea.  The booking bit is for certain. The choice is a bit of a hot potato although it is a political imperative.  Practice Based Commissioning on the other hand has a remit to restrict choice, and use "Care Pathways" and redirect patients from hospital services.  There is a clash of policy between choice and practice based commissioning.  G.P. "off tariff" providers will not be allowed on C&B.

It is a good idea that G.P.s could book patients in to outpatient clinic direct form their desk, so both the doctor and patient know there is an appointment in the system.   The trouble is the interface to do that is GHASTLY:  It is back to front.  When booking a flight on the internet one chooses the flight, and THEN book it and THEN put in one's name and card details.  The NHS demand the name NHS number and details FIRST, and checked, and then fight though drop down windows and much mouse clicking (there are no quick keys or shortcuts) does the doctor find that the department they both chose, does not do on-line booking....7 minutes into a consultation.

There is another advantage of C&B, in that it is more secure and private method of  making referrals.  That is true. The data is encrypted, the letters read by clinicians.  At the conference  it was stated an  average of 22 people handled a standard written G.P. referral from G.P. to hospital doctor, and all could if bothered read the letters.  It strikes me that there is a staffing problem in the NHS if that is the case.

At the conference the Connecting for Health team members that I spoke to seemed to agreed with the following:

1. The bandwidth of the current broadband connections (256K uplink) is not wide enough for G.P.s to use hosted systems. The plan is that all G.P. systems will be centralised and served from data centres. This is the NHS "solution"  All data should be held off site, and not remain in G.P.s surgeries the moment it is typed in.   The cheat that some working systems use is to have some form of local server, and store and forward the data.  Connecting for Health LSPs remains opposed to local servers.

2   G.P. systems are fast, and the only clinical systems used in front of patients.  The UK still leads the way in this field, with 100% of practices with working clinical systems from 10 suppliers, four main suppliers left. Destroying what we have is now seen as madness.  G.P. systems are now being looked at as a basis for the Microsoft £40M common clinical interface.  It looks as if the best ideas of current systems will be thefted in this way (Microsoft has seldom been credited with inventing new concepts...just taking over others).

3  The Choose and Book interface is a mess.   In all the propaganda and leaflets you see smiling clinical looking at screen with pointing mouse and drop down menus.  At last the interface team recognise that use of mice in a clinical situation SLOWS YOU DOWN.

Practical problems: The lack of help lines.
The Connecting for Health team present at the conference were not  surprised by my experience of using Connecting for Health systems.  We now use swipe cards that authenticate who we are.  The software that does this is complex.  It installed (we are not on version 4) on the practice computers, except on two machines.  One these machine every software component was there but one part not was talking to the next.  There is no real technical help line.  It is not up to one's clinical system supplier, as the software is not theirs. The Local Service Provider does not talk to G.P.s directly, the PCT did not know the answer. There is no national email help, nor a sensible discussion group with a few techies on board.

Even the Connecting for Health technicians working on the project suffered similar issues.  After many phone calls and emails the official technical Connecting for Health answer to my problem came as follows: Wipe the disc and re-install windows XP, office and clinical interface, re-map drives, re-install sophos spyware, dns,gateway, etc etc..  That was the dumb advice from a multi-billion contract:  There is nobody you can contact who knows the code, the registry entries or anything. There is no board or chat room to converse and exchange such information.  The failure on some machines for NHS authentication to install is a well known problem (especially for machines that have been upgraded to XP).  I spent all afternoon un-installing the the Connecting for Health products and then removing every reference to the components in the registry, and re-installing it  It worked then, but I have no idea which line that needed removing, that got the beast to work.  Nor it seems does the multi-billion Connecting for Health organisation know or care.  Us G.P.s are mere pawns, and ignorant ones at that, so cannot be talked to on such matters.

I came away from the conference a little less depressed about Connecting for Health.  After £Millions wasted, it looks as if the intense antagonism against Primary Care and G.P. working current clinical systems has been diluted.  However the Local Service Providers, who have to host these clinical systems, were not present at this conference. The Local Service Providers still insist, for their own commercial reasons, on pushing their preferred monolithic mouse driven systems, working off site, using the NHS 256k uplink. Those systems were often conceived in America, where clinical use by doctors in front of patients in surgeries is rare, except for billing.

Gerard Bulger

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