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6 eHealth contribution to NHS Scotland's strategic aims

The strategic agenda is set by the Better Health Better Care Action Plan and its three main sections are adopted below as a framework on which to set out how eHealth will contribute to realising NHS Scotland's clinical and business priorities.

1. Towards a mutual NHS

Delivering together on information confidentiality

Patient confidentiality is a critical theme which runs as a common thread through IT-enabled change and information sharing. We will continue to move forward in a way which maintains the confidence of patients and clinicians.

Key action: The proposed NHS Charter of Mutual Rights will be a clear statement of duties and rights from the perspective of Government, healthcare staff and the public. It is proposed that the handling of personal information relating to patients will be included in the consultation. The kind of questions to be explored, with a view to consensus emerging, include:

• How can NHS Scotland best support a productive partnership between professionals and patients?
• Is it accepted that safe and secure electronic arrangements for records is to the benefit of patients?
• If patients choose to withhold information, what are the implications for them and for healthcare professionals?
• For all parties concerned, what are the rights and obligations?

These discussions will feed into improved policies on information assurance building on the strong track record of NHS Scotland. It will also include new proposals for management of confidentiality arrangements, including a presumption that the public will be represented in scrutiny arrangements. New developments in how services to patients are delivered will also be taken into account - with patient journeys increasingly crossing between NHS Boards, we need to ensure that information flows are not impeded by arrangements that were set up for intra-Board care.

Performance management and service planning

Information to support performance management plays a key role in the management and planning of services. Work is already being undertaken to align the eHealth programme and project portfolio with NHS Scotland's HEAT framework and other key corporate objectives. A particular focus is alignment with the national improvement programmes, including patient safety, 18 weeks Referral to Treatment, cancer, long term conditions and mental health.

Whilst much of the focus of eHealth is to support the direct care process, there are significant secondary benefits from being able to derive statistical data for clinical audit, benchmarking, monitoring of services, service planning, and public health activity. Information for such secondary purposes must increasingly become a by-product of clinical recording, as opposed to a parallel process that incurs duplication of effort.

But where eHealth can make a particular difference is through provision of real-time operational information. So in addition to improved statistical services, the key action will be to exploit existing and new IT systems to provide increased real-time operational management data. This will include use of SCI Gateway and SCI Store to support the information and reporting framework for the 18 week programme.

Managed Clinical Networks

eHealth has already provided information systems to support managed clinical networks ( MCN), in particular to enable sharing of patient information between clinical professionals to improve the safety, efficiency and effectiveness of care. To date eHealth's focus has been in the area of the common cancers and diabetes. However, in line with the Long Term Conditions ( LTC) theme of Better Health Better Care, a key action will be to do more to support MCNs in these areas. An associated action will be to ensure appropriate information governance/ confidentiality controls are built in.

2. Helping people to sustain and improve their health, particularly in disadvantaged communities

An enabling health service

Better Health Better Care announced the creation of a National Health Information and Support Service to provide a single shared health information online resource for patients. This will have a key role to play in supporting initiatives which build people's capacity to improve their health and wellbeing, addressing issues such as smoking, drug and alcohol misuse, diet and sexual health. The key action will be to support the option of a web-based channel for this new service, by working with the organisation designated to lead on delivering the initiative.

Mental health

Mental health and wellbeing is a complex area and Better Health Better Care identifies a wide range of initiatives for the future agenda. In terms of information systems support it raises the challenges of input from a wide range of clinical professionals, working across sectors but seeking to provide integrated care to patients. The key actions will be to exploit existing systems to support the Mental Health Benchmarking initiative and support for Integrated Care Pathways where possible plus the procurement of a Patient Management System to replace current PASs and meet wider functionality requirements within the secondary care setting. This will include those for mental health, and provide support for information sharing across teams that work across NHS, local authority, and voluntary settings.

The best possible start

Child health information is important to policies such as Getting It Right For Every Child and existing and new immunisation programmes such as that to combat cervical cancer with the HPV programme. Building on comprehensive work already underway, the key action will be to modernise and develop child health systems in accordance with the general principles of the strategy.

There is in addition the particular challenge of information sharing to support vulnerable children with contributors to care from different agencies. This is of particular significance where child protection is an issue. It is beginning to happen, with for example some partner agencies now using the technology available nationally known as the eCare Framework. Progress will be encouraged and, in addition, there will be a project to define and deliver a child health summary with an initial focus on integrating nationally-held child information.

Tackling health inequalities

Better Health Better Care highlights health inequalities and the importance of targeting support and better enabling people to manage their own conditions. Anticipatory care through screening and health checks is another area where eHealth can make a significant contribution, while supporting the NHS' equality and diversity obligations. Key actions will include:

• The technology which holds the national Community Health Index ( CHI) of Scottish patients' identification details will be replaced and modernised. This will include the ability to record the patient's ethnicity details and better capabilities to select sub-sets of the population according to defined criteria for screening.
• An action plan will be designed in collaboration with the Long Term Conditions Alliance and the national improvement programme. This will build on progress already made with electronic records to support diabetes care and trials of home monitoring devices designed to identify deterioration in patients' health status. The action plan will address eHealth support in areas such as education, shared care plans, condition monitoring, self-care, and support for carers.
• The necessary changes to GPIT systems will be commissioned to reflect any contractual changes, in particular to enable targeting and anticipatory care for patients living in deprived settings. This will include building on the work already undertaken to support the identification of patients at risk of hospital admission, and working with Community Health Partnerships that are pursuing programmes with community partners.

3. Ensuring better, local and faster access to health care

Safety & effectiveness

There are a range of eHealth developments of importance to the safety and effectiveness agenda:

a. CHI-based patient record identification

Each NHS Scotland patient has a unique number known as the Community Health Index. Use of this number allows elements of the patient's record to be reliably brought together and viewed by authorised clinicians. Significant progress has been made in promoting the use of this number in preference to local numbers. The key action now is to shift to full scale use of the CHI number as the primary identifier.

b. Support for direct patient care

The patient's journey of care often crosses between different NHS sectors and indeed other service providers e.g. local authority, voluntary sector. The eHealth Strategy will support improvement in both the care provided within an NHS sector but also assist in passing the baton of care between sectors.

There is already strong investment within primary and community care, with for example support for services such as community pharmacy which include installing broadband telecommunications for pharmacists with follow-on projects to support the minor ailments service and medication services.

Within the secondary care and mental health sectors, patient management systems which support the administration of appointments and inpatient stays are, in some Boards, all but obsolete. Moreover, eHealth support for clinical test ordering and note taking is patchy at best.

The particular needs of patients with long term conditions cared for through Managed Clinical Networks means that specialist patient record systems are needed to ensure co-ordination between the many contributors to care. NHS Scotland has had significant success developing specialist IT systems to support key conditions such as diabetes, and the work of the Scottish Diabetes Group and NHS Tayside is acknowledged here with the SCI Diabetes Collaborative system now live across Scotland. The key action will be to continue this approach while ensuring it is underpinned by common standards so that systems can be re-used in other NHS Boards. The work will be taken forward in conjunction with what was described earlier - direct involvement of patients and their carers in their eHealth.

New key actions will involve procurements for a range of modern IT systems to support direct patient care in all care settings.

The first procurement will be for a Patient Management System ( PMS), where a consortium of five NHS Boards is being supported to procure and implement an IT system which enables both in-patient and out-patient efficient patient scheduling and waiting time management, with additional features such as online test ordering/ results reporting and scope for further functional modules such as A&E, theatres, electronic prescribing and maternity. The system selected will be available to all NHS Boards.

The second procurement will be focused on replacing the GPASS (General Practice Administration System Scotland), with a date for ending the GPASS service and a migration plan to be agreed between NHS Boards, SGHD and NSS. This will be part of broader programme of support for improving eHealth in primary and community care which will include:

• a Primary/ Community Care eHealth Development Fund to be allocated to Boards which comprises two elements: funds to enable NHS Boards to have direct contractual relationships with their suppliers of GP systems and in addition support for community NMAHP eHealth development (see below for more on this);
• plans agreed with NHS Boards on how the fund will support Shifting the Balance of Care⁴ including links with partner agencies , with local re-investment of any savings made from changing GP system supplier;
• a national framework contract set up to give NHS Boards with their stakeholders choice of GP systems that comply with national standards;
• options for NHS Boards to determine their preferred approach to meeting the needs of community NMAHPs.

The third procurement will be at the heart of our Strategy. It involves the development of a services 'Clinical Portal', which can be described as a single online entry point through which various elements of information related to a single patient can be accessed by authorised users. This will avoid the need for repeated and separate log-ons and searches, which is a major issue for clinicians today. Moreover, there will be improved controls over access to patient information based on the role of the user related to their need to discharge that role.

NHS Tayside, Fife and Greater Glasgow & Clyde have done work in this area, which shows great promise. At a national level the focus will be on the standards and technology to support access control within Clinical Portal, which can then be adopted by selected local IT systems.

Taken together, these new procurements, set alongside current systems such as PACS and Emergency Care Summary, will provide a solid basis to our progress towards shared records between contributors to a patient's care.

c. Medications management

The Scottish Patient Safety Alliance has highlighted that a vital element of patient safety is medication, where there is a known risk of errors both in the act of prescribing ( e.g. wrong doses) and in lack of knowledge of the patient's current prescriptions and allergies. While the Emergency Care Summary ( ECS) has made a big difference to the latter risk in the unscheduled care setting, it is still an incomplete picture given the range of prescribers. Additionally, mitigation of the first risk - IT-enabled support for prescribing itself - is virtually absent outside of general practice.

The vision is a single medication record, available to authorised prescribers, with intelligent support for prescribing. However this vision is a long term challenge, not least due to the need to approach it with care so as to avoid introducing fresh risks to patient safety.

The key action will be for the consortium of NHS Boards taking forward the Patient Management System procurement to include Hospitals Electronic Prescribing & Medications Administration ( HEPMA) as one of the options when going to the market.

d. eHealth patient safety assurance

eHealth has a significant contribution to make to the safety of care, for example with the Emergency Care Summary. We will focus on the support which eHealth can make to the improvement agenda set out by the Scottish Patient Safety Alliance. However eHealth should not itself introduce risks to patients, so for example if patient information is passed from one electronic patient record to another as part of a referral then what is sent by one clinician must be exactly what is seen by the recipient clinician. Arrangements for assuring eHealth patient safety need to be agreed, and this will done in collaboration with the Scottish Patient Safety Alliance.

Community health and social care

The Scottish Government sees improvement in this area as key to shifting the balance of care. It involves multi-disciplinary working and information sharing, for which the availability and use of modern information sharing tools is important. NMAHPs work across all health, social care and educational sectors, which emphasises their requirements for integrated information. Staff working more closely at the health/ social care interface may derive clinical communications benefit from using social care systems. Those working mainly in health may benefit from the clinical functionality of the PMS procurement across acute and community sectors. Staff closely aligned to general practice teams may benefit from using the GP system. The ability to appropriately share clinical information and extract summary reports and service information to meet NMAHP management is an essential component of this mixed model.

The process of Single Shared Assessment is essential to the provision of both health and social care, with for example, occupational therapy staff assessing care needs of patients pre-discharge to enable them to live safely and effectively in the community. Although much of this work currently relies on paper-based systems, some partner agencies are beginning to use the eCare Framework technology to do this electronically.

Given this evolving picture, and differences between NHS Boards, the strategy for supporting this area will be flexible and incremental. Key however is the fact that considerable benefit can be achieved through exploiting eHealth services that exist yet are not currently available to all NMAHPs who work in the community.

The strategy will therefore be based on the concept of levels of eHealth maturity, with the expectation that progress up the levels will be sequential rather than all achieved at once. The three levels are:

a. IT enabled services

Actions here will address basic provision of networked PCs and staff trained in their use. Targets will be agreed with each NHS Board and central funds will be made available to support the required investment.

b. Informed and communicating

This level addresses benefit from making available existing NHS Scotland eHealth services, tailored where necessary to the needs of NMAHPs who work in the community. Again based on agreed targets and plans with NHS Boards, including pilots, the services to be introduced may include:

• Secure email suited for patient-related communication, through NHS Mail
• Sending and receiving referrals, discharge communications transfer or shared care information through SCI Gateway
• Online access to relevant local information such as clinical letters, test results and the child health summary sourced from SCI Store
• Online access to clinical knowledge.

These existing services are all available to authorised users via the network-connected devices which forms part of the basic infrastructure in Level A. Additional packages will also be available as part of this infrastructure, such as word processing.

A further and specific type of electronic communication relates to exchange of Single Shared Assessments with partner agencies. Consideration will be given to developing the features of SCI Gateway for this.

c. Fully supported

This level of maturity is where NMAHPs who work in the community use a specialist electronic patient record which offers features such as appointment scheduling, information recording and care planning.

The current position on availability of such systems across NHS Scotland is variable. Some NHS Boards have systems or are developing them, although with evolving business needs in this sector they may not be future proof. Other NHS Boards are exploring the usefulness of using existing Patient Management Systems for community NMAHPs. Finally, while the procurement to replace GPASS must focus on meeting the needs of GP practices, it may be that the selected system will offer useful features for NMAHPs.

The optimum approach for EPR support for NMAHPs who work in the community will become clearer in due course, and to inform that there will be encouragement for small focussed projects which will be evaluated. A key action will be to evaluate current and evolving models of care and use the specification for AHPs, midwives and community nursing, mental health nursing that has been developed as part of the IPACC (Integrated Primary and Community Care system) and PMS projects to continue to inform the debate.

Patient centred and equitable

Better Health Better Care emphasises that an effective self-management framework requires that patients and their carers receive accessible, plain, clear, appropriate and timely information. The work to establish a National Health Information and Support Service is relevant to this policy aim.

Nevertheless, our commitments to equality and diversity mean that an internet 'channel' to information cannot be the only route, and eHealth will work in collaboration with organisations such as NHS 24, who specialise in telephone-based patient support.

eHealth may also be able to contribute to self-management by giving patients the option to have access to their own records and care plan and the ability to add to the record for example, self monitoring information, via secure internet services. The Emergency Care Summary system is the obvious candidate to base this upon, and options around these areas are currently being studied.

The key action will be to discuss the possibilities for patient and carer access to electronic records with the Long Term Conditions Alliance and other patient interest groups. It is expected that this will result in an evaluated trial to assess benefits, and inform next steps such as offering such a service to all NHS Scotland patients.

eHealth will also have a role to play in supporting sustainable remote and rural health services. As described in a recent report ⁵, electronic patient records and electronic communications will offer critical support to healthcare professionals in remote areas and centres and within Extended Community Care Teams ( ECCT). Key principles set out are:

• That specialist advice can be provided from a distance by videoconference, telephone or e-mail
• Travelling to a central point can be avoided by the use of videoconferencing to a rural general hospital ( RGH), community hospital, GP practice or indeed in certain circumstances direct to a patient's home
• Digital data such as test results can be shared from remote sites with other points, enhancing diagnosis capability. RGHs could therefore supply a network of community hospitals and/or a tertiary centre could likewise give specialist support to the RGH, community hospital and isolated practitioners.

To address these aims, eHealth will continue to support developments in the area of telecare and telehealth through the Scottish Centre for Telehealth to expand the effective application of tele-conferencing/ tele-consultation and image transfer to support remote delivery of services. This will also include promoting the application of these technologies to support professional education. eHealth also recognises the importance of telecare in promoting anticipatory approaches to service delivery, and its role in the re-enablement and rehabilitation of patients.

Efficiency and timeliness

eHealth's contribution to efficiency and timeliness can be seen across the board, nevertheless three initiatives can be highlighted:

a. Reduction in waiting times to 18 weeks

Meeting the target will require significant streamlining of patient care administration, as well as new models of clinical management. eHealth will have a major role to play in enabling the achievement of this target. In addition to interim measures based on incorporating new definitions and exploiting SCI Gateway, of direct relevance is the Patient Management System procurement. This will bring in a modern IT system where it is needed to support more efficient management of patient care through facilities such as online referral management and appointment scheduling, efficient management of resources such as theatres, and innovations such as text message reminders.

b. Electronic transfer of records between GP practices

Half a million patients join or leave GP practices every year in Scotland. Each change requires the entire record to be moved, which is a laborious and sometimes slow process. With GP records increasingly being electronic, there is scope for considerable improvement by being able to transfer the records electronically. Decisions on the best way forward are being considered as part of a business case process.

c. Support for workforce planning and human resources

Work has been underway with a view to investment in a common human resource management system. The focus of this work is to improve capability in key areas including the availability of workforce information for planning purposes, understanding of staff competencies and skills, and assessment and management of training requirements. The key action will be to complete the business case which will form the basis for final decisions on the form and scale and timing of investment in this area.

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