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13 CHAPTER THIRTEEN INFORMATION AND COMMUNICATIONS TECHNOLOGY

01 In all the work we have done, one issue came up again and again. It was high on the priorities of clinicians, managers and members of the public. A common information technology system that will provide the 'glue' for an integrated NHS seems to be a universally accepted requirement.

02 Given the huge increase over recent years in personal computer and internet use as well as the dramatic changes in ICT use in other industries, most people might assume that the NHS is highly electronic and computerised. The reality, however, is that the a high proportion of its business is still not computer based. In hospitals, patients' medical notes and records are still, overwhelmingly, folders of forms and handwritten notes.

03 The reasons are not difficult to find. One of the key factors is the lack of investment. Figure 13.1 shows the relative spend per employee on information technology across a number of sectors of the economy. Health care lags far behind.

Figure 13.1
Annual expenditure per employee on Information and communication technology in United Kingdom in different economic sectors, 2000

04 The implications of the absence of an electronic record are considerable. For example, it introduces significant and unnecessary inefficiencies to the system. Work in the United States suggests that:

• something like 1 in 7 hospital admissions occur because care providers do not have access to previous medical records,
• 20% of laboratory tests are requested because previous investigations are not accessible,
• 15% of hospitalisations are complicated by drug error.

Why do we need information technology?

05 We are not alone in thinking that a dramatic acceleration of information technology provision is an essential means to achieve service change in health care. The Department of Health (DoH) in England is embarking on a major programme for information technology. Under the headline "Better information for health and patient care, where and when it's needed", the DoH say;

"Better information leading to better health and care for every patient is at the heart of the National Programme for IT ( NPfIT). It's transforming the way information flows around the health service, making it possible to deliver faster, safer and more convenient patient care. At the same time it is giving patients the information they need to look after their own health."

06 Likewise, the US Department of Health and Human Services said in July 2004, on the back of a major Presidential initiative to promote IT in health care:

"Information technology can result in better care (care that is higher in quality, safer and more consumer responsive) and at the same time, more efficient (care that is appropriate, available and less wasteful). There are few other alternatives that can achieve both of these goals in a balanced and timely manner."

07 Of course, we have known this for some time in Scotland. In the 2002 report of the GPASS Review Group, the anticipated benefits from a national electronic patient record were summarised as follows;

• Enhanced quality of care
• Enhanced safety of care
• Verifiable quality, safety and outcomes of care - underpinning standards and clinical governance
• Integration of care - improved patient-centred care irrespective of site or agency (self, primary, intermediate, secondary, tertiary or social care)
• Better informed patients and health professionals
• Higher quality data for improved planning of services and informed policy development, including public health
• Novel opportunities for education, research and development and health informatics.

08 There is a reference in virtually all of our individual reports to the need for an integrated information system. We will not rehearse the demands once more in this chapter but by way of illustration, the following section from the Care in Local Settings work provides an indication.

09 The Care in Local Settings Team recommend that an essential component of a system of care in local settings (which is to be the vehicle for a shift away from reactive, crisis-management, acute-oriented care towards anticipatory, preventative and continuous care) is a comprehensive health care information system which includes an electronic health record. If patient care is to become anticipatory rather than reactive then patients must not be allowed to 'disappear from the radar'. As outlined in Box 13.1, an integrated health information health system plays a key role in implementing systematic care for long term conditions as outlined in the influential Chronic Care Model.

10 Information systems should be able to support the three functions of assessment of need, care planning and co-ordination and evaluation of the quality of care.

11 Assessment of need or risk stratification. Registration of all individuals with long term conditions or ongoing health problems forms the basis of assignment to the appropriate level of care co-ordination and management - from some form of intensive case management or care co-ordination for those with the most complex needs to supported self-care for the bulk of the population with less severe long term conditions.

12 Care planning and co-ordination. An integrated electronic health record will not in itself provide co-ordinated and integrated care. However it is a crucial pre-condition for the provision of co-ordinated care by members of a multi-disciplinary team. The Electronic Health Record ( EHR) enables patient records to be accessed as appropriate from across the system. Amongst the key functions of such a system would be health information and data storage (including images), results management and dissemination, order entry ( e.g. for prescription drugs), decision support, referral protocols and capacity and patient information.

13 Patients and carers must be active partners in the provision of co-ordinated care. Remote monitoring and patient self-monitoring in the context of an integrated information system will enhance their ability to participate in care and will enable care co-ordination and monitoring to be performed on a more systematic basis.

14 Monitoring quality of care/quality improvement. The electronic health record will be indispensable for monitoring patient outcomes and the application of quality improvement methodologies to care in local settings.

What do we need?

15 Our work tells us that the NHS needs a single information technology system with the following key features:

• An Electronic Health Record
• Picture Archiving and Communications ( PACS)
• Electronic prescribing
• Electronic booking
• Remote monitoring facility
• Tele-medicine facilities

16 The electronic health record is at the heart of the information requirements. It is central to NHS reform and will transform the way health and social care information is managed. It must give health and care professionals access to patient information where and when it is needed. It must meet the needs of patients and give them access to their own private health records.

17 Currently, health information is held as a mixture of paper based and computer records that can't easily be shared. Even records held electronically are effectively 'locked away' on computers that can't talk to one another. We need an electronic health record ( EHR) that will change this by digitising our 5 million patient records, allowing information to be shared safely across the NHS. A patient will be treated by a variety of care professionals in a range of locations throughout their life. The EHR is a means of ensuring that the central details of the care and treatment are held in a single, easily accessible, electronic record.

18 The record needs to store a patient's essential personal details like their address, date of birth and importantly, a unique patient identifier (known as the CHI number). Over time, it will build their health and care history. It will include information such as whether a patient is diabetic or has a drug allergy, as well as details of the treatment and care they have received, building up a comprehensive patient history. This means, for example, that if someone from Dumfries is seriously injured while on holiday in Aberdeen, they can be treated by a local doctor with immediate access to the patient's medical records. The doctor can be informed of any drug allergies and previous treatments, ensuring that life-saving treatment can begin immediately. It will also mean that when a patient telephones NHS 24 the Nurse Advisor has instant up to date information about the patient which will both improve the quality of the advice and the efficiency of the intervention.

19 We have looked at the Computerised Patient Record System ( CPRS) developed by the Veteran's Health Administration. The CPRS displays the patient record in a way that supports clinical decision making. It shows timely patient-centred information on its front page, including active problems, allergies, current medications, recent laboratory results, vital signs, hospitalisation details and outpatient history. The CPRS delivers an integrated record covering all aspects of patient care and treatment including:

• electronic order entry and management ( i.e. the facility to order and manage requests for diagnostics),
• narrative notes entry (idealy this should be voice activated so the clinician can dictate notes directly into the system),
• laboratory results display,
• consultation requests,
• alerts of abnormal results.

The CPRS supports clinical decision makers throughout the system whether they are in primary care, a local hospital or a major centre.

20 There are considerable benefits to be gained from introducing an electronic patient record. The National Programme for Information Technology summarise the benefits as follows:

For patients:

• Improved quality and convenience of care
• Assurance that the right information about diagnosis and treatment is available when and where it is needed
• Improved communications with health and care professionals
• Immediate treatment can be given in an emergency as the patient's medical record is known
• Confidence in the accuracy and appropriateness of information in the patient's record
• Absolute confidentiality of care records through the unique NHS number, password protection, and a trail of any access ( i.e. by whom, when and where) attached to a record
• Patients have access to their own record and the opportunity to become more involved in their own care
• Patients have opportunities to confirm details of their appointments and prescriptions

For clinicians:

• Greater support in diagnosis through the NHS Care Records and easier access to up-to-date information
• Improved information and support through access to patient records and diagnoses 24 hours a day, seven days a week
• Knowing which care providers have been involved in treating a patient
• Reduced administration and less duplication of record-keeping
• More efficient and appropriate referrals and communications of test results and discharge summaries between, for example, GPs and hospitals
• Increased safety in prescribing and monitoring prescriptions, and warning about possible conflicts in treatment
• News about changing trends in diseases

For the National Health Service:

• A transformed service focused on the individual patient with improved care experience and confidence in the service
• Savings in cost and time from cutting out paper-based transactions, filing and storage, to be replaced by automatic filing and archiving
• Greater integration of health and social care services
• Better quality information to support research, audits, and performance management.

21 We recommend that the Scottish Executive secures an electronic health record system with the functionality described above. The work of the GPASS Group referred to earlier suggests that the EHR should be purchased and introduced in line with the following guiding principles.

• Patient-centred care requires patient-centred records (not unit, agency or professionally based records as at present)
• Accessible, complete and accurate information to be available in the right place and at the right time for the benefit of both patients and health professionals
• High clinical functionality essential for the specific locus of care and for the professional administering that care
• The system must be highly secure and resilient (available 24/7) with robust technical back-up guaranteed
• Patient confidentiality must be assured at all-times, access levels agreed for each individual health professional and access audit trails in place
• Systematic arrangements should be in place to ensure standardisation, maintenance and updating of hardware and software
• Adequate training support/programmes essential for all users - including the promotion of excellence in health informatics.
• Ownership and priority setting for developments requires necessary and sufficient "buy-in" by users of the system - including patients. Mechanisms need to be robust and transparent to secure this. Will require clinical leadership at all levels to secure this (national, regional and local, strategic and logistic)
• Appropriate and sufficient resources to be made available to underpin all of the above.

22 We recommend that the EHR should be put in place within 3 years. Consideration should be given to purchasing a proven 'off the shelf' package rather than developing something specific to Scotland. It should be compulsory not optional and should result, over time, in a paper free system. It should be capable of interface with social care systems and the CHI number (patient identifier) should be recognised across the health and social care systems to ensure a joined-up approach.

23 Picture Archiving and Communications Systems ( PACS) capture, store, distribute and display static or moving digital images such as electronic X-rays or scans. PACS takes away any need to print on film and to file or distribute images manually. This means that as images are created they can be immediately sent and viewed across several NHS locations. These digital images should form an essential part of every NHS patient's EHR. They should extend not just to X-rays and scans, but to pathology slides, cardiology results, wound photos, endoscopies etc.

24 Electronic imaging, such as PACS can transform patients' experience of the care they receive as well as enable clinicians using any sort of image to provide a much faster, more effective and straightforward service. The particular benefits will include:

• More effective care as clinicians and care teams work together in one or more locations (much easier to separate the capturing of the image from the reading of it - meaning the image can travel rather than the patient)
• Faster access to high quality medical imaging services and results
• Reduced re-testing
• Quicker discharge from hospital and better care planning resulting from easier access to images and test results
• Fewer appointments and operations postponed because of non-availability of images
• Images available 24 hours a day, seven days a week
• Simultaneous image viewing across multiple sites and locations
• More efficient use of facilities and staff.

25 The NHS in Scotland needs an electronic prescribing system similar to the Veteran's Administration's Bar Code Medication Administration ( BCMA). Electronic prescribing can increase patient safety by reducing prescription errors and providing better information at the point of prescribing and dispensing. This also creates the opportunity to reduce adverse drug events where the patient responds poorly to medication. The prescription information should form part of each person's NHS care record.

26 An Electronic Booking Service allows GPs and other primary care staff to make initial hospital or clinic outpatient appointments at a convenient time, date and place for the patient. When a patient needs to be referred to a consultant or other healthcare practitioner they will be asked by their GP where they want the treatment to take place. They will then be able to 'book' the appointment on the spot and leave the surgery with their appointment time and date. This will replace the paper-based referral system and work in tandem with the proposals for referral management centres referred to in the section on elective care. It should remove the lengthy wait (often weeks) between visiting the GP and receiving an appointment from a hospital.

27 The potential benefits include the provision for patients of greater choice of date, time and place for their appointment, better planning and management information through tracking of referrals - reflecting local needs - and more consistent, accurate and efficient referral information with none of the delays of paper correspondence.

28 Remote patient monitoring will facilitate support and management of patients across Scotland. Integral to the EHR, patients can be remotely assessed and early intervention instututed where necessary. Patients as well as professionals will be able to update the EHR thus ensuring real-time and comprehensive patient data is captured.

29 Tele-medicine. The final, vital component of the information and communications technology required to support the implementation of our Report relates to tele-medicine. We use tele-medicine here as the descriptive term for any application of ICT which removes or mitigates the effect of distance in health care. This may involve technologies as simple as the effective use of the telephone, through digital transfer of informattion, advice and images, to real time video-conferencing and consultation.

30 Amongst the reasons why telemedicine solutions should be considered are:

• Where there is no alternative, or it would be prohibitively expensive to provide the service by conventional means.
• Lack of staff with appropriate skills. This could be as a result of the specialised nature of the clinical task, the lack of experience, training or education of the healthcare professional, the difficulty of providing cover on a 24-hour basis, or because of problems recruiting and retaining staff.
• To improve the quality of service for patients ( e.g. faster access, less travel).
• To improve the quality of the working environment for staff in order to improve staff recruitment and retention ( e.g. access to training, peer support, information and advice, networking confidence/morale enhancing).
• As a means of providing professional education and development.
• In order to concentrate and improve access to expertise, especially where skills are highly specialised or limited in availability ( e.g. pathology).
• To reduce costs ( e.g. by reducing the need for face-to-face appointments, or minimising the need to travel).

31 Whilst the use of communication technology may produce better efficiency both within and between organisations, it has traditionally been seen as being used to overcome problems of distance. Therefore, Scotland with 20% of its population living in remote and rural areas and with its surrounding islands is ripe for re-design of healthcare delivery facilitated by technological solutions.

32 The Scottish Executive established the Scottish Telemedicine Action Forum ( STAF) in 1999 to progress the introduction of communication technology for clinical care. STAF commissioned a number of demonstrator projects with the main focus being the introduction of communications technology to routine clinical care. STAF issued its initial report in January 2003 which highlighted a major obstruction to re-design as being the failure to convert successful projects to routine service. Combined with this has been a reluctance to embrace the potential for such projects to be used across traditional boundaries within the NHS such as primary to secondary care and across regions.

33 The most highly developed of the original STAF projects is the emergency tele-medicine initiative based in Aberdeen Royal Infirmary. Our work on unscheduled care identified the Aberdeen programme as an example of good-practice for how we will deliver unscheduled care in the future. The aim of the project was to establish a robust telecommunications infrastructure to be initially used to provide emergency care. The infrastructure is also available to deliver planned clinical care as well as education initiatives. The core project is described in Box 13.2.

Summary of recommendations

The NHS in Scotland needs a single information technology system with the following key features:

• An Electronic Health Record
• Picture Archiving and Communications ( PACS)
• Electronic prescribing
• Electronic booking
• Remote patient monitoring
• Tele-medicine facilities.

The electronic health record is at the heart of the information requirements. It is central to NHS reform and will transform the way health and social care information is managed.

The Scottish Executive should secure an electronic health record system with the functionality described in this chapter. The system should be put in place within 3 years. Consideration should be given to purchasing a proven 'off the shelf' package rather than developing something specific to Scotland. The system should be compulsory not optional and should result, over time, in a paper free system. It should be capable of interface with social care systems and be based on universal usage of the CHI number.

Local health care systems should be based on a comprehensive population based health information system able to support the functions of: risk stratification/ assessment of need; care planning and co-ordination; and quality assurance and improvement.

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