Many of the problems of the connecting for health programme are listed on the CFH website here

Connecting for Health pushed the following themes at the conference:

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.

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, that was started before Connecting for Health, that is 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 readcodes 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, although a telephone call the next day would iron out any real difficulties about a patients history.  It seems obvious at first, 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 or any other hospital you have attended.  It would save time and effort for the team to be able to read, from anywhere in the UK, that the G.P.s records stated that  your were an epileptic or an alcoholic.

That is just the problem.  Doctors, on seeing a new ill patients must start afresh, take a history and examine the patient.  There are huge risks in relying on previous diagnoses and computer entries, making us lazy, and closes an open mind.  You stagger into casualty with slurred speech.  The casualty doctor will  reads on the Integrated Care Record that you have an alcohol problem according to the (teetotal) GP's clinical record, so the casualty doctor parks you in a corner to sober up.  Alas you are staggering about because you have had a small stroke, or that you have cerebellar problems from undiagnosed low thyroid levels.

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

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.

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? A rash once when given penicillin given as a child?  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 guts with 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 codes as "allergic" to it on a previous occasion.  So how we record allergies and what we mean by them is complex.  For a G.P. allergy recording may mean little more than getting his system to help the surgery team avoid upsetting the patient again by giving X,  but for a hospital doctor that same information may be taken as an injunction NOT to give the drug under any circumstances, assuming that there is a high risk anaphalaxis.   Data on G.P. computer systems were collected for use within the surgery.  To use this data for a National data set to be used by others adds an astonishing level of complexity ot 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.  What must be done add another line to state the line above, or referring to the one many lines above is, was wrong.  So a patient wrongly diagnosed as allergic to penicillin has to have another entry to say the opposite, although currently the read coding system does not cater for this. Negatives, incorrect entries are deleted.  The is no NOT...read code.  I am not sure how negatives are to be put on the system at all.    Some practices have 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 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 what 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 bit of a hot potato, and that is a political imperative.  Practice Based Commissioning remit is to restrict choice, and use "Care Pathways" and redirect patients from hospital services.  There is a clash of policy on 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 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.  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 clinical interface.  The idea is to have a common 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 no help lines.
The Connecting for Health team present at the conference were not  surprised by my experience of using Connecting for Health. We now use swipe cards that authenticate who we are.  The software that does this is complex.  It installed well (we are not on version 4) on the practice computers except on two machines.  Every component was there but one part not was talking to the next.  There is no real technical help line.  It is not one's clinical system supplier. The Local Service Provider does not talk to G.P.s, the PCT did not know.
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 have the same issue.  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.  The failure on some machines 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 what one line that needed removing, that got the beast to work.  Nor does the multi-billion Connecting for Health organisation.  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 its working systems has been diluted.  However the Local Service Providers, who have to host clinical systems, were not present at this conference, and they still insist, for their own commercial reasons, on pushing their preferred monolithic mouse driven systems working off site up a 256k uplink, These systems were often conceived in America, where clinical use by doctors in surgeries is rare, except for billing.

Gerard Bulger