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Health in Scotland 2004

CHAPTER 5: eHEALTH

Introduction

Whatever the focus of the health agenda, from healthcare associated infection to waiting times to assessing quality of care, information technology (IT) plays a critical role. Health is the last of the public sector domains to benefit from the introduction of robust IT and the reasons are many. The lack of standards in medical record keeping, concerns over privacy and confidentiality, meagre and poorly directed investment and the highly publicised failure of public sector IT projects have made some clinicians reluctant to participate. However, this has begun to change and the Electronic Clinical Communications Implementation (ECCI) programme in Scotland has given a new impetus to developing technology that genuinely supports the way clinicians work.

Scotland has a long history of leading work in eHealth. For close to two decades, most Scottish GPs have used a single software package, developed in Scotland, called GPASS. The Scottish Executive invested £5m over three years from 2000 in the Scottish Telemedicine Action Forum. The current Scottish eHealth programme was set up following the commitment given in Partnership for Care to establish an eHealth culture, driven by clinical leaders.

The eHealth Programme Board and its subgroups provide co-ordination of the various elements required for a successful IM&T (Information Management and Technology) programme - technology, culture, clinical engagement and consideration of the patients' interests and requirements. Standardisation is at the core of the eHealth Strategy and it is policy to move towards a single electronic health record for each patient in Scotland accessible according to role and legitimate clinical need. This will be managed jointly by patients and clinical staff with in-built security and supported by patient consent.

At the core of Scotland's eHealth Strategy are the SCI (Scottish Care Information) suite of products, especially SCI Store (a clinical data repository) and SCI Gateway (a tool to support secure and standardised communications between clinical domains). Significant gaps in the functionality (the entirety of functions expected of a system) available to NHSScotland have been filled by national procurements. NHS Boards are bound to take the national product unless they can present a robust business case to the contrary. So far this approach has been applied to Accident and Emergency Systems and Picture Archiving and Communication Systems (PACS). The latest such procurement is of the Generic Clinical System toolset designed to be used to create disease/problem specific systems incorporating national information standards.

ECCI Programme

More than a third of GP referral letters are now delivered electronically. SCI Gateway ensures that information is structured and can be incorporated into hospital systems. All GPs in Scotland have access to electronic results reporting via SCI Store and a pilot project in Glasgow is publishing all clinical letters to SCI Store. Access to laboratory and radiology reports with clinical letters will prove extremely valuable for the next consultation.

National Clinical Datasets Development Programme (NCDDP)

Currently, medical records are distributed in time, place and media with multiple paper records and electronic records for every patient. Adherence to standards will allow interoperability between geographically separated carers and reliable access by patients. The NCDDP is pivotal to this. Electronic systems cannot share information without certainty that clinical staff all use the same definitions. This ensures precise clinical and technical definitions are applied and agreement is reached on 'bounded code lists' for use in systems. Most importantly, this work in Scotland is being co-ordinated with similar initiatives in the field of social care and datasets are incorporated into the Health and Social Care Data Dictionary.

The NCDDP has been operational for a year and has made considerable progress in the areas shown in Table 5.1.

Table 5.1. Progress by NCDDP in 2004

The Phase 1 Generic Core Dataset is the first piece of interagency work to produce an agreed dataset. The next phase will include agreement on ethnicity, smoking and alcohol intake. The importance of standardisation is percolating through to clinicians, especially those involved in setting up Managed Clinical Networks, thus the work of the NCDDP will expand rapidly. Resources must be matched so that this step is not rate-limiting.

Generic Clinical System

The Generic Clinical System toolset will be used to create systems with a common look and feel tied to the Health and Social Care Data Dictionary so that information standards will be synchronised. The tools will be used in multiple ways from supporting audit to making clinical information available across MCNs. Early implementation will focus on mental health and cancer.

National Programme for Information Technology (NPfIT)

In England a radical reform of the NHS is underway supported by the largest IT project in the world with £6.1 billion being spent over 10 years on software and hardware alone. Implementation costs will be four to five times this amount. All existing systems will be replaced with standard software and all encounters with patients will be reported to the Spine which will accrue a summary record of the patient's health history. This will be available, on a need to know basis, across England. Scotland will not adopt NPfIT in its entirety but will use some of the solutions: the Drug and Medical Devices dictionary and the SNOMED-CT terminology will be implemented throughout NHSScotland. Strenuous efforts will be required to ensure that clinical information can be exchanged across the UK.

Telemedicine

The Scottish Telemedicine Action Forum initiated projects to show that technology could provide better access to specialist advice for those separated from the major centres. These projects are incorporated into the eHealth agenda since they are not about the tools but about providing solutions to clinical problems using appropriate technology. Numerous examples of enhanced care exist, for example Yorkhill Hospital now has links to units around Scotland and is able to provide neonatal surgical and cardiac opinions with live video and ultrasound images.

GP computing

Much of the electronic medical record material in NHSScotland resides in GP computers and 85% of Scottish GPs use the GPASS software. The recent changes in primary care have necessitated major changes in the way GP systems operate. Many improvements have been made and a review will determine the medium term plan for Scottish GP systems. Many practices have moved to a paperlite (the neologism used to describe an almost paperless place) environment by the implementation of scanning software.

The Emergency Care Summary project extracts recent medication and allergy information from GP systems and makes this available to out-of-hours clinical staff. This will develop to include A&E and ambulance staff and the scope will also grow to include significant past medical history. Such initiatives dramatically improve patient safety. All such work is supported by patient involvement and consent.

There is a clear consensus among clinicians that ehealth is not an optional extra for NHSScotland. Electronic information management is the key to improving the quality and safety of patient care as much as a tool for the efficient and effective management of the health system. There is a welcome determination, now backed by significant investment over the next three years, to deliver this vision and to ensure that in doing so NHSScotland has an IM&T system which is fit for purpose and in line with international best practice. Delivering value to patients for this investment will require sustained effort, careful programme management and significant cultural change among the NHSScotland workforce.

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