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Words from the BCS HealthInformatics Forum vice chair

them up. Many of the same themes were apparent at aworkshop run by the Worshipful Company of InformationTechnologists on electronic patient data integrity and privacythat I attended on behalf of BCSHIF. A report of the eventwill be published.

By the time this issue of Health Informatics Now appears,BCSHIF will also have attended a meeting run by theWellcome Trust to consider ‘The use of electronic patientrecords for research and health benefit’.

Some of those who attended HC2007 will rememberquestions raised during one of the panel sessions about thescalability of some of the technology on which NHS CFHrelies. An external proposal to investigate the generic issuesinvolved in more detail is currently being considered byBCSHIF and other experts within BCS.

BCSHIF Health Informatics Ethics handbook

Stocks of this popular publication, the first of its kind, havealmost run out, so we are taking this opportunity to rewrite itwith the support of the Canadian informatics community.

Jean Roberts will lead the work. We will seek help fromthe BCS Ethics Forum, as well as ensuring that the outputaccords with the revised ethical code produced by the RoyalAcademy of Engineering. The International MedicalInformatics Association (IMIA) has agreed in principle toadopt it as a global policy.

UKCHIP

Congratulations to the UK Council for Health InformaticsProfessions (UKCHIP), which recently registered its thousandth IT practitioner. UKCHIP is currently refreshingits strategy, and relationships have been established with theBCS professionalism programme, acknowledged as a worldleader in the field.

ASSIST

The ASSIST / NHS CFH annual conference in Leeds was aswell attended as ever, and delegates heard about the progressof NHS CFH, the NHS Information Centre and the work ofthe NHS Institute for Innovation and Improvement.

The ASSIST AGM was as usual held on the same day,and was notable for reaffirming the merger of ASSIST andthe BCS, and selecting Brian Derry, director of informatics,Leeds Teaching Hospitals NHS Trust, as ASSIST’s newchairman. We are delighted to welcome Brian onto theBCSHIF Strategic Panel.

Our report ‘The Way Forward for NHS Informatics’ (seewww.bcs.org/hif/cfhreport) continues to attract considerableinterest, and the BCS Health Informatics Forum (HIF)Strategic Panel will finalise the work plan to follow it up atthe next Forum meeting in July. Within NHS Connecting forHealth (CFH), review and change have continued at all levels.The Parliamentary Public Accounts Committee review ofNHS CFH (see www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/390/39002.htm) was published in April, and echoed many of the conclusions of ourreport.

Our activities led to the BCS President Nigel Shadboltbeing invited to an event hosted by the secretary of state forhealth Patricia Hewitt that also included included the NHSCEO and leaders from NHS CFH and their major contractedsuppliers. Concerns about communications and incentivisingthe take-up of NHS CFH applications by the NHS figuredprominently in the discussions.

During the event it was indicated that NHS CFH wouldlike to work cooperatively with the BCS on an agreed set ofspecific activities to help improve the programme, aninvitation that we shall be taking up.

The English electronic patient record

This is among the most controversial elements of the NHSCFH strategy, and is attracting much attention inside andoutside NHS CFH. BCSHIF responded to the Health SelectCommittee of the House of Commons enquiry into ‘TheElectronic Patient Record and its use’, and this and the manyother written responses and oral evidence can be seen atwww.publications.parliament.uk/pa/cm/cmhealth.htm#evid

The committee has been sufficiently roused by what it hasheard and read to schedule two additional hearings, and mayarrange more. Audiovisual recordings of the hearings areavailable for 28 days after each event, and can be at found onits website.

Late last year we decided to organise two workshops onthe electronic patient record, the first in Glasgow in Februaryand the second in March at Portmeirion in north Wales. Theseproved both extremely lively and interesting, and this issuecontains a summary of the events and how we plan to follow

Ian HerbertEmail: [email protected]


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HEALTH INFORMATICS NOW is the

newsletter of The British Computer Society

Health Informatics Community.

It can also be viewed online at:

www.bcs.org/forum/hinow

HEALTH INFORMATICS NOW is a

quarterly publication. The deadline for

contributions to the September 2007 issue

is 23 July. Please send contributions to

[email protected]

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Sheila Bullas (leader), Keith Clough,

Andrew Haw, Ian Herbert

Editorial team

Editor: Helen Boddy

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Forum

2 Words from Ian Herbert, the vice chair of the BCS Health Informatics Forum

4 Industry news

6 Linking up to break down boundaries

9 Blurring data widens record sharing options

10 Records workshop: the number’s up

12 Wales: pragmatic progess on IT programme

14 Northern Ireland: healthcare delivery and academia join forces

16 Scotland: standards open up border crossing

18 Scotland: knowledge shared is knowledge doubled

20 Are we nearly there yet?

21 Glyn Hayes reaps reward

27 Forthcoming events

Specialist and Member Groups

Scotland

22 Meet the group

Northern

24 Decision support for medicine

26 NPfIT – the inside story

CONTENTS

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New website to supportpatient choice

A new website, NHS Choices, willgo live this summer with the aim ofthe public and clinicians being ableto access a range of NHS serviceinformation through one gateway.

The website will include:searchable comprehensivedirectories; comparative data onhospital waiting times, cleanlinessand readmission rates; medicalliterature on treatments; and guideson the most common procedures.

It is part of a package unveiledby health secretary Patricia Hewittto help patients in disadvantagedcommunities. Another initiative ispiloting library schemes in 10 areaswith specially trained librarians tohelp patients to choose and book.

Other products will includeaudio programmes for streaming tolocal radio stations, televisualcontent to burn onto DVDs, andpamphlets to print off at publiclibraries or the GP surgery.

Pick up your prescription,prompts voicemail

It will soon be possible for pharmacists to leave an automatically-generated voicemailfor patients to collect prescriptionsvia Message Dynamics’ new system. The company has reached aheads of agreement to integrate itstechnology with Cegedim Rx’sPharmacy Manager and Nexphase.

Pharmacies are already usingtext messaging to contact patientsbut voicemail will allow them toreach the over-65s who often donot own mobile phones.

NHS Direct handles 1,000sof polonium enquiries

The NHS Direct helpline handled3,791 calls about poloniumbetween 24 November and 18December 2006. Following thedeath of Russian, AlexanderLitvinenko, the website had 44,204visits to its health alerts, news andradiation on polonium, whichequalled 4 per cent of overall visits.

Urgent remedial high-level action isneeded for the National Programme forIT (NPfIT) if the long-term interests ofNHS patients and taxpayers are to beprotected, according to the CommonsPublic Accounts Committee (PAC). Areport by PAC printed on 26 Marchstated that the Department of Healthneeded to address the conclusions andrecommendations made in the document.

PAC is appointed by the House ofCommons to examine the accountsshowing the appropriation of the sumsgranted by parliament to meet thepublic expenditure.

The overall report conclusions were:

The shared electronic clinical recordis already two years behind schedule.No firm plans have been published fordeploying software to achieve it.

Suppliers are struggling to deliver,and the programme is unlikely to becompleted anywhere near its originalschedule.

There is still much to do to winhearts and minds in the NHS, especially

PAC recommends urgentaction on NPfIT

Telecare is moving towards widerspread adoption due to a range ofrecent moves.

Health secretary Patricia Hewittannounced on 23 May that new sitesthat will use hi-tech home healthcare tohelp older people and those with long-term conditions, such as heartdisease, to lead more independent livesand help prevent emergency hospitaladmissions. Teams in Kent, Newhamand Cornwall have been awarded £12million to look at how best telecareservices can be implemented.

A month previously, science ministerMalcolm Wicks proposed to the Houseof Commons science and technologycommittee to track the movement ofthe elderly with satellite technology. Hetold the BBC that this could enablethem to lead fuller lives, freedom toroam, and reassure their families.

Meanwhile, remote monitoring of

patients with chronic heart failure hasbeen shown to be effective by a reviewpublished in the BMJ. The reviewdemonstrated that tele-monitoringreduced admissions to hospital forchronic heart failure, cut deaths by allcauses by nearly one fifth and improvedhealth related quality of life.

among clinicians. The programme needsto deliver on its promises, supplysolutions that are fit for purpose, learnfrom its mistakes, respondconstructively to feedback and win therespect of a highly skilled andindependently minded workforce.

There is still uncertainty about thecosts and value of the benefits that theprogramme should achieve.

The report calls on the Departmentof Health to: publish an annualstatement outlining the costs andbenefits; commission and publish anindependent review of the businesscase; and review local service providers’(LSP) performance against theircontractual obligations.

The chair of the PAC EdwardLeigh said the programme, ifsuccessfully delivered, still offeredhuge benefits, but warned that if itfails ‘it could set back ITdevelopments in the NHS for years’.

The report can be found at:www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/390/390.pdf

Telecare spreads its reach

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Survey highlights patientsafety as main concern

Implementing technology to reducemedical errors and promote patientsafety is the most important priority for a group of CIOs surveyed in the USA. Asked to identify their top five priorities, 54per cent of 360 IT respondents inthe HIMSS Leadership Surveypicked the above.

The other top five prioritieswere: replacing or upgradinginpatient clinical systems (identifiedby 48 percent of respondents);implementing an electronic medicalrecord (48 per cent); businesscontinuity/disaster recover (35 percent) and integrating systems in amulti-vendor environment (34 percent). Furthermore, 18 per cent ofrespondents indicated that theirorganisation has experienced asecurity breach in the past sixmonths. The survey is at:www.himss.org/2007Survey

UKCHIP Register reachesone thousand members

The 1,000th person has joined theUK Council for Health InformaticsProfessionals Register. It is a register of health informaticianswho voluntarily apply and havebeen assessed as fit to practice ininformatics to support health.

Samaritans receives accoladefor email service

The email service of Samaritans,which provides confidential emotional support, has landed thecharity a special award.

The email service was hailed formaking a difference by the judgesat the annual national eWell-BeingAwards, which identify andrecognise projects that use ICT todeliver social, economic andenvironmental benefits.

First introduced in 1994 andfunded by The Vodafone UKFoundation, the email service wassubstantially developed in 2003. In2005, samaritans received 154,000emails.

The overrunning of the consultationschedule was responsible for the delayto the electronic patient record in theview of Richard Granger, according to e-Health Insider. This was reportedlythe crux of his argument in giving oralevidence to the House of CommonsHealth Select Committee as part oftheir investigations. This followed thereport from the Public AccountsCommittee on the National Programmefor IT (NPfIT).

He reportedly said that the majorityof the programme would still bedelivered by 2010, with the spinecentral infrastructure due to bereleased by this time next year.

He said that the main problem isfinding a pathway between twoextremes – waiting patients and privacyfascists.

He labelled medical consensus onthe national programme as oxymoronicand said that the challenges were

because of the ‘tribal nature of medicalpractice meaning different stances andpostures’.

In a later session, Dr Paul Cundy,chair of the General Practitioner’sJoint IT Committee, Dr MartynThomas, representing the UKComputing Research Committee andAndrew Hawker, a former systemdeveloper, reportedly dismissedGranger’s comments and called for anindependent hearing into NPfIT.

When asked if he felt an independentreview was necessary, Granger reportedlysaid: ‘Are the people calling for itthemselves independent? We have aprogramme under immense scrutiny, andthe minister took a decision last year thatsuch a review was not necessary.’

The hearing received 68 pieces ofwritten evidence. See:www.publications.parliament.uk/pa/cm200607/cmselect/cmhealth/422/422we01.htm

Consultation blamed forrecords delays

BT, the local service provider(LSP) for London, is to deliver aconfiguration of Cerner Millenniumfor London that differs from thatprovided for NHS Trusts across theSouth of England, according to areport by e-Health Insider.

The software will not be altered, e-Health Insider understands, but adifferent configuration will lead tothe system having different features.

BT’s decision is reportedly dueto problems with Millenniumprocured from LSP Fujitsu at thefive initial NHS sites in the Southof England.

79 staff at Milton Keynes hadearlier signed a letterrecommending that no other Trusttake Millennium until problemswere resolved as they believed itwas not yet ‘fit for purpose’.

London’s configuration tostand apart

Only one in three GPs intend to advisepatients to allow their medical recordsto be shared using the NHS SummaryCare Record, according to a survey by

Pulse magazine.The majority of respondents believed

that sharing records threatened patientconfidentiality.

The majority of GPs areagainst sharing records


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Linking up to breakdown boundaries

A reassuring note for health informaticians was sounded at the startof the HC 2007 conference: Lord Hunt,minister of state for quality,Department of Health, emphasised theimportance he attaches to the role ofIT to the healthcare arena in hiskeynote speech.

‘As minister for quality, the numberone issue is raising the bar for qualityof care, and using IT as much aspossible to do that… There’s noquestion in my mind that we need todevelop our systems.’ he said. LordHunt had only taken up the post tenweeks earlier, although it is an areawith which he is familiar from hisprevious appointment as aparliamentary under secretary of statewith the Department of Health between1999 and 2003. He resigned from thepost in protest over Iraq.

A host of topics were covered in thefive streams at the three-dayconference, run by BCS HealthInformatics Forum (BCSHIF). Theseincluded UK-wide nationalprogrammes, understanding healthcare,professionalism, clinical systems, userneeds and systems requirements.BCSHIF members presented a largenumber of the papers and chaired manysessions.

Alongside the conference, theBritish Journal of HealthcareComputing and InformationManagement ran an exhibition withmore than 100 exhibitors. As well asdemonstrations of technology on fairlyconventional stands, visitors were ableto climb aboard a bus, and visit avirtual patient’s clinic.

England’s National Programme forIT (NPfIT) was mentioned in many ofthe presentations. Topics addressed

The electronic patient record, the issue exercising many in healthcare, was the subject of many presentations at this year’s Healthcare Computing conference. This article by Helen Boddy focuses onthe health record, as well as interoperability, another recurring theme at the conference.

included progress made, lessons learnt,next steps, centralisation versuslocalisation, interoperability, and issuesin moving towards an electronic patientrecord – from policy and strategy topractical tips from those implementingsystems.

Delegates also heard presentationson the different approaches beingadopted in Scotland and Wales andtheir experiences of introducingelectronic patient records (seefollowing articles).

NPfIT goes local

In his speech, Lord Hunt admitted thatNPfIT to date had not always gonesmoothly, partly due to its centralisednature.

‘I think the national approach to theprogramme was the only way to haveachieved change with any scale at all,’he said. ‘We have now made sufficient

progress to change the focus to localownership.’ This was the reasoningbehind the recent creation of the NHSLocal Ownership Programme (NLOP).

A less centralised approach toNPfIT was backed by other speakers atthe conference. Prof Colin Tully, one ofthe gang of 23 academics whoproposed a technical review of NPfIT,described the programme as ‘too big,too fast and no one knows where it isgoing.’ He proposed devolving it to itslowest level.

Lord Hunt also admitted that tryingto do too much too quickly had causedsome of the problems associated withNPfIT, a view echoed by other speakersat the conference. Ian Herbert, vicepresident of BCSHIF, commented thatNPfIT is trying to overcome someproblems that were in the NHS beforethe advent of NPfIT, such as patientrecord control. ‘They [Connecting forHealth] are hitting rocks because they

Lord Hunt opened the conference


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are going so fast,’ he said.The speed of the letting of the first

contracts has also resulted, accordingto Phil Sissons of Magic Consulting, insuppliers being confused as to whatthey had agreed to deliver.

Lord Hunt was at pains to stressthat progress had been made, mostrecently with the GP2GP recordtransfer and the trials of the SummaryCare Record. The Croydon PCT hadstarted using the GP2GP system a fewweeks earlier. ‘By 2008, we expect it tobe available to 45 million patients,’ hesaid. ‘Given that 3.5 million patientschange GP each year, an extraordinarymobility of patients, this scheme willmean that instead of records taking anaverage of six weeks to be transferred,they will be there for the GP to see atthe patient’s first appointment. Thisissue of slowness of transfer of recordshas been a historic problem and nowwe have a chance to tackle it.’

Complexity of electronic records

Lord Hunt admitted, however, that theelectronic health record has been lessof a success story. ‘The nationalSummary Care Record containing theclinical record has been delayed byaround two years against the originalplan,’ he said. ‘There are all sorts ofreasons for this. It is partly due to itscomplexity, partly because of the needfor consensus on its contents, and partly because of patientconfidentiality.’ He admitted that in thepast too much had tried to be done tooquickly, and that the pace would therefore now be moderated. Effortswould now focus on: electronic prescriptions; electronic prescribing;Acute Trust Patient AdministrationSystems (PAS); and integrating primary and secondary care.

He highlighted that security of theelectronic patient record was animportant issue, and that care must betaken to address public concerns.

In a session devoted to the personalhealth record, Murray Bywater, directorof Silicon Bridge Research, commentedthat the ambitious nature of theelectronic health record should not beunderestimated. ‘No other country hasone for more than 4 or 5 millionpatients, and the largest successfulscheme is the Veterans Association inthe US with 6-7 million. Even they,

when pressed, admit that although theyare identical systems, they areimplemented differently.’

‘Scalability, complexity andavailability have to be looked at for thetechnical platform [for the electronichealth record]. Something may work atthe GP level but it’s more difficultwhen scaled up.’

Phil Sissons, however, was of theopinion that, given that England’s GPelectronic health record is the ‘best inthe world’, Trusts ought to be broughtup to a par with them, after which thesystems can be joined together.

This was all too much too quickly,however, for several speakers whosuggested taking a step back to firstdefine the electronic health record sothat ‘we know when we have one, andmore generally to decide exactly whatthe programme should be delivering’.

Ian Herbert suggested the problemwas more fundamental still: ‘NPfIT is amisnomer. There is no such thing as anIT project, merely business projectsenabled by IT. Colin Tully agreed thatthe way forward has to be as a businesschange programme.

Given that Ian views NPfIT asbeing about business change, heidentified another problem: insufficientfunding has been allocated to trainingstaff. ‘So far NPfIT is under spent, butwe still need more money thanallocated when you take into accountthe training needed to accompany abusiness change programme.’

Generally speakers considered thesuccess of the programme crucial to theprovision of high quality care and werekeen to participate in resolving thecomplex outstanding issues to ensurethis success. This was highlighted bySheila Bullas. She described how thePrincess Alexandra Hospital, incommon with others, had started andstopped procurements as new nationalstrategies came along ‘suffering fromplanning blight’ and ‘always at the endof the list to get systems’. As a resultthe hospital desperately needed theprogramme to succeed.

‘We now need an open discussionabout the way forward,’ advocated DrManpreet Pujara, a GP in Rochester,and chair of the EMIS National UserGroup. Much could be achieved throughmore communication involving allhealthcare stakeholders, includinghealth informaticians.

A member of the audience called forConnecting for Health (CFH) to engagewith the health informatics community,as well as with clinicians. He expressedconcern that CFH had not come to theevent. ‘If CFH is not at meetings tolisten, as well as to contribute, how canwe go forward?’ he asked.

Nevertheless, Phil Sissons suggestedthat the future was looking brightergiven that the NHS chief executiveDavid Nicholson has highlighted goalsfor NPfIT that he, Phil, could not haveput better himself:

Make sure NHS and users areproperly engaged.

Reduce the scope of NPfIT.Replace the bunker mentality with

an open approach.

Interoperability counts

Interoperability is going to play a bigpart in ensuring future success of systems, suggested speakers.

Various technical solutions relatingto different interoperability scenarioswere presented at the conference, aswell as more theoretical points beingpresented. A demonstration of theConnectathon was run throughout theevent by Integrating the HealthcareEnterprise, an internationalorganisation that is concerned with thecommunication of information betweenmedical devices and clinicians.

Semantic web fits with health

Joining up information got a mentionvery early on in the conference whenBCS President Nigel Shadbolt gave akeynote speech on the semantic web,which has the potential to help join upcertain pieces of information.

‘With the semantic web, we can

Nigel Shadbolt


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build services so that the patient recordis generated automatically from otherpatient information. Health informaticsis about core content issues, and thesemantic web is right up its streetbecause it is, for instance, aboutequipping content with rich metadataand ontologies.

‘In health informatics you’ve beenorganising terminologies already, via forexample SNOMED CT. The differencewith the semantic web is that theinteroperability exists on the web.’

One of the driving features of usingthe semantic web is being able to trackhow information is changing, heexplained.

Half way on user interfaces

One interoperable solution that is closerto being ready to use is the CommonUser Interface, as Andrew Kirby ofMicrosoft Solutions explained at theconference. The Common UserInterface is aimed at clinicians whooften use systems supplied by differentvendors to do the same task, and wastetime learning and remembering how touse the different desktop interfaces. Connecting for Health has thereforetasked Microsoft Services to come upwith a toolkit that will help ensure thatall vendors create similar desktopapplications – the Common UserInterface. The four-year project is nowhalf way through, and 40 of the proposed user interface guidelines havenow been developed.

Telehealth guidelines

Guidelines for interoperable telehealthare also in the process of being developed. One presentation focused onthe work to join up telehealth by theinternational Continua Health Alliance,a collaboration between more than 100companies including medical devicemanufacturers, technical companies,drug companies and healthcareproviders. Continua is selecting devicesthat are interoperable – the sensors,connectivity and computation products– and is joining them up.

It aims to enable some healthcare,such as for chronic diseases, to moveout of the hospital and into the homevia personal telehealth, explained DavidWhitlinger, president of the ContinuaHealth Alliance, and director of

healthcare device standards andinteroperability of Intel Corporation.

Uses of joined-up telehealthsolutions could include monitoring theelderly with results from sensors, ontoothbrushes, and pill minders, forexample, fed back to loved ones tocheck their behaviour was normal. Ifnot, sensors could be linked into asystem that would raise alarms.

David said that Continua expects topublish guidelines on which productsare interoperable by the end of the year,and give them certification and logos.

On questioning, David admitted thattelehealth is still expensive, but heexpected that there would be a scaleadvantage when more of these productsare adopted. He further said thatstudies show that quality of healthcareis better from telehealth compared tobeing in hospital.

If a patient is sent home to conductself-monitoring, for instance for chronicdiseases, the hospital is no longer paidfor that patient, and it comes under theremit of social care, pointed out KevinDean in a presentation about emergingtechnologies. There is a risk that suchorganisational issues constrain progress.

He believed that there are still fewreally connected health applications,despite all the talk of eHealth. Hehighlighted the Map of Medicine (whichdetails 370 care journeys for cliniciansso that they can refer to best practice)as being the first time that anapplication joins up primary, secondaryand tertiary care.

Non-technical considerations

Furthermore, according to Kevin, interoperability is not just about technical developments. There are somehuge non-technical questions such as:

How do we make sure content is safe?Who’s going to design the systems?Who’s in control of them?

Ian Herbert also identified some non-technical interoperability issuesregarding the electronic health record.‘There are questions of who owns therecord and what information should beshared,’ he said. His point was emphasised in an ‘UnderstandingHealthcare’ session at the conferencewhen a hospital consultant commentedthat it wasn’t helpful to him to receive40 years worth of notes on a patient;he much preferred a concise summaryof the current problem from a GP.

But will GPs even be around to seeinteroperability of the patient record?Kevin suggested that that in 10-15 yearsthere maybe won’t be enough doctors tosee all their patients, so we will receiveautomated healthcare. Furthermore, it ispossible that virtual worlds such asSecond Life could maybe provide somesort of answer, he said.

‘Compared to what Lord Hunt saidabout not going too fast too quickly, it’s avery different world,’ Kevin said ‘We needto keep up.’ Read Lord Hunt’s speech at: www.dh.gov.uk/en/News/Speeches/DH_073343

The HC2007 conference proceedings contain 22 papers and16 posters covering a wide range ofcontemporary health informatics topics addressed during the conference. Also included is a copyof the BCS report ‘The WayForward’. Copies of the conferenceproceedings are available in bookform (£20) and CD-ROM (£7)including p&p from:

HC2007 Conference SecretariatAmicus ConferencesPO Box 357Worcester WR3 8WT

Tel: 0845 370 8182 (Judy Hayes)Fax: 0845 370 8183Email: [email protected]

HC2007 conference proceedings


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Blurring health datawidens sharing options

access the system, encryption and auditlogs, and surveillance of which data isaccessed and for what it is used.

When data is to be made availableto a wider community, there is no needfor it to include patient-identifiabledata. Rob explained, however, thatsimply pseudonymising data was notsecure enough as ‘inference’ could beused to work out patient details bylinking some information to otherknown information, such as detailspublicly available on the electoral roll.Inference attacking was publiclydemonstrated in August 2006 whenpseudonymised search records werereleased by AOL only to then beidentified by journalists using thesemethods.

‘Inference attacks are the biggestweakness,’ explained Rob. ‘For example,if you know when someone has visited adoctor, you can work out which recordmust belong to that person if no-oneelse has visited the same variety ofhealthcare providers on exactly thesame sequence of days. It is our thesisthat if we deal with inference attacks

we can open up the data to a widergroup.’

Sapior has therefore developed asolution in which similar values in allfields are grouped and then blurred tomake each record non-unique. Thetechnology radically extends ‘k-anonymity’. The idea is that at least ‘k’records are made the same with justone identifying field being different.

K is derived from the risk of illicitre-identification associated with theuser of the data – the greater the risk,the bigger the k, and the more blurredthe data is that they receive. Thereforethe riskier the recipient, the moreblurred the data would be that theyreceive.

‘If records are ambiguous we canstop inference attacks from happening,’claimed Rob.

Sapior is running a trial of itssystem this year with a commercialcompany and is looking to run a trialwith an NHS body (the InformationCentre for Health & Social Care, forexample). Anyone interested shouldcontact [email protected].

To predict the most likely reasons foremergency service call-outs, reliabledata sets of health problems need to beanalysed. To do so, it is not necessary toknow the details of individual patients’illnesses, as long as they can begrouped together.

There are various other scenarioswhere government, research institutes,commercial developers of healthcareproducts and other bodies could usehealth data to improve healthcareservices through research and analysis.

‘There is quite a lot of value inhealth data,’ said Rob. ‘There are a lotof new applications to analyse datapatterns. Pharmaceutical companieswant to see if their drugs make adifference. There is also an emergingtrend to develop preventative medicalreminders, for instance for familiesdisposed to certain hereditary healthconditions.’

Sapior has therefore developed away of blurring health records datathat would make individual patientrecord data unidentifiable so that it canbe released to a wide set of governmentagencies and commercial bodies. Theimportant thing is that it is not possibleto deduce or infer from this dataanything about an individual patient,while keeping it meaningful in terms ofbeing able to distinguish, for example,geographical patterns.

Rob made it very clear that whatSapior is looking at is not aimed atclinical use of data where NHS staffneed to be able to see details about thepatient sitting in front of them. In thatcase blurring of data would not beappropriate. For staff looking at actualpatient data, he suggested instead thatdetails would be kept secure by role-and time-based control of who could

Being able to share health records is not just about passing patient details between clinicians who dealwith the same patient; the data is also valuable for research and analysis. Rob Navarro of Sapiorexplained at the BCSHIF meeting in April how his company is looking at blurring health records so thatdata can be used by a wider community. Helen Boddy reports.


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The number’s up

The way forward for the ongoing work on electronic health records was put under the microscope at arecent BCS Health Informatics Forum (BCSHIF) workshop. Peter Murray, founding fellow and directorof the Centre for Health Informatics Research and Development (CHIRAD), provides a round-up of thewide-ranging discussions.

‘I am not a number, I am a free man.I will not be pushed, filed, stamped,indexed, briefed, debriefed or numbered.’

This is one of the most famous quotesfrom the 1960s TV series ‘ThePrisoner’. Portmeirion in Wales, wherethe series was filmed, was an ironic (oriconic) setting for the second of twoworkshops on health records, givenwhat we in the UK, along with manyother countries, seem to be trying toachieve in terms of numbering, indexing, filing, and so on of many elements from our health records.

This article provides my initialreflection on the workshop proceedingsand pulls out what I think were some ofthe interesting issues.

The two recent workshops inGlasgow and at Portmeirion broughttogether BCS Health InformaticsForum (HIF) members, clinicians (GPs,hospital doctors and nurses),academics, health records managers,and others. All four home countrieswere represented at the events, pluswider European participation fromNorway and The Netherlands.

The events were held in Wales andScotland to emphasise that BCS is aUK-wide organisation, and try to avoidthe narrow thinking of NHS Connectingfor Health’s English approach.Discussions started by sharing anunderstanding of what is meant byelectronic health, medical and patientrecords, ongoing work, and theirimplications.

The further aims were to identifythe major issues to address, for the UKand international interest, and whatneeded to be done. We also wanted, asSheila Bullas, one of the workshopleaders emphasised, to get away from anavel-gazing discussion about the past,

avoid ‘motherhood and apple pie’statements and engage in some criticalthinking about the way forward.

A wide range of issues emerged, andthere were differing views on thepriorities for addressing them. TheGlasgow event highlighted many issuesspecific to Scotland, and the ScottishExecutive’s different approach. Whilethe Welsh event did not focus as heavilyon Welsh issues, it was clear that formany of our Welsh colleagues, the bestapproach would be very different fromthat of Connecting for Health.

Interoperability required

Many technical issues emerged, as didthe need for systems to support interoperability, especially across borders, and long-term access torecords in the event of system changes.However, I want to highlight more ofthe cultural and organisational issues.

Issues of access to records,including who should have access andfor what purposes, issues of culturalchange and the impact of electronicrecords on professional practices werediscussed, along with the implicationsof telehealth and other futuredevelopments on the nature and use ofelectronic records. The participants sawthe development of electronic recordsnot only from technical viewpoints, orfrom their own professionalbackgrounds, but explored many of thewider implications.

Discussions included the changingrole of the patient and theirexpectations, the implications ofdemographic change and the possiblecreation, or reinforcement, of digitalexclusion and disadvantage, and theneed to move to a real health service,rather than simply a crisis-responseillness service.

The integration of paper andelectronic records and the necessarymigration from legacy systemsgenerated much discussion, especially atthe Scottish workshop. Patientscurrently have multiple paper recordsheld in many different locations bydifferent health professionals, and oftenfor differing purposes. Is it thenadequate to scan paper records into anelectronic record and call themelectronic? There are many issuesaround the structure and coding of suchinput, around how the information istranslated into an identifiable format,and about future access.

The practical and philosophicalissues of a move to integrate all ofthese into possibly one lifelongelectronic record have, it was felt, beenvastly underestimated, and the idea of‘one patient, one record’ is probablyunsustainable. This seems to have beenrecognised in the Scottish Executive’s‘Delivering for Health’ strategy, whichseeks to move towards different modelsof care delivery (‘away from reactive,crisis management, acute-orientatedcare towards anticipatory, preventativeand continuous care‘) and for acomprehensive set of information andcommunication systems built aroundthe electronic health record. Thestrategy explicitly states that ‘patientswill have access to their own electronichealth record’.

Patients at the centre

Moves towards more patient-centredness and greater collaboration,in both healthcare delivery and so, ofnecessity, health records, were seen asinevitable. As more patients use a widerrange of healthcare services, we willneed to explore the nature of the‘healthcare team’ and who has


11

legitimate access to the record(s).Should local pharmacists have access,should homeopathy practitioners?Should they have access to other partsof the record? The rights and obligations of a wide range of stakeholders will need to be exploredalongside the role of the patient indetermining rights.

Will politicians be brave enough tovest ownership, and control of access tothe record primarily with the patient?Irrespective of how far along this roadwe go, there was a view that the patientwill be central to consent and controlperhaps in a ‘primus inter pares’ (firstamong equals) role. However, with thevariety of records that exist we cannotadopt a ‘one size fits all’ approach tofuture health records.

We have legislation on theownership of the record, but this wasfelt to be flawed, as might be the wholequestion of ‘ownership’. Participantswere keen to see work undertaken todeconstruct the issue of ‘ownership’ ofrecords, explore whether it is a usefulconcept, and whether a better set ofdiscussions might be around who hasrights of access to the record and whoholds copies of it; even whether ‘therecord’ might be viewed differently, as itis often a composite of different thingsfrom different sources.

There were unsurprisingly differentviews of what ‘the record’ is: each aversion of the truth from a differentperspective; each setting the boundaryin a different place. Work to addressshared understandings will be vital;structure of records is good, contextmay be even more important.

Collection criteria

Records contain data collected at specific times, and, in developing anyrecords architecture, thought must begiven as to determining what data tocollect – and to store long-term – witha view to what might be needed or relevant in the future. This is particularly relevant when those contributing to the record are not necessarily those who use it, with theresult that much that is implicit mustbe explicitly recorded.

The current digital recording ofclinical measurement and imagesresults in an explosion of data whichwill require additional tools forvisualisation. It was felt that there isnot sufficient understanding of thisissue and that a computer scienceperspective is required.

There was concern about whethercurrent developments, based on today’sor even yesterday’s technologies, takesufficient account of technologydevelopments we already know of orcan predict. In the future, will we needlarge, industrial-modelled electronicrecords, or should we look towardssmaller, decentralised and patient-specific databases? What areimplications when ‘you are your ownrecord’ through the use of wearable and implantable devices and personalarea networks? Will we need to start again and spend another £12 billion for the NHS to catch up with the technology that the rest of the word will be using? Does the information ‘pull’ approach epitomised bybrowsing others’ records (or a

single centralised one) replace the ‘push’ approach (represented byencounter messages, referral requestsand discharge messages), or is it justan adjunct to it?

We considered what sort of societywe wanted and recalled the warning ofinformation commissioner RichardThomas that the UK could ’sleepwalkinto a surveillance society’ as a resultof collecting more and moreinformation about people that isaccessible to many people and sharedacross many boundaries; just whatshould shared health and care recordsaim to do?

This report provides the meresttaster of the breadth and depth ofdiscussions. So, where do we go fromhere? An action plan is beingdeveloped. BCSHIF can, and will, playa major role.

Given the scope of the actions, manyother organisations will need to beinvolved as well. Much of the workmight only be possible through thenational organisations responsible forimplementing electronic health records,and cannot be undertaken alone byvolunteers within a charitableorganisation such as the BCS.

‘As more patients use

a wider range of

healthcare services, we

will need to explore the

nature of the ‘healthcare

team’ and who has

legitimate access to

the record(s).’


12

Wales pursues pragmatic progressWales is approaching its IT strategy, Informing Healthcare, in its own quiet and unassuming way, saysDr Robin Mann MBBch MBCS. Here, he reviews the progress and plans of the devolved Welsh initiative,which includes the introduction of the individual health record.

after Information for Health) but Walesnow has more than one tenth of itspopulation served by the first incrementof the ‘Individual Health Record’ (IHR)– a health record containing theinformation, considered by clinicians tobe the most important for the overallcare of the individual – available in ‘outof hours’ centres throughout the south-east of Wales.

The initial deployment was startedon schedule and within budget, andwhen complete one third of the overallpopulation of Wales will have individualhealth records. The informationgovernance model has been developedwith the BMA (the chair of the EthicsCommittee is on the group) and otherprofessional and local bodies. Thechallenging informatics issuesassociated with the integration of datafrom different source systems havelargely been resolved, and ‘highlysensitive’ data has remained firmly inthe hands of the people the public trustthe most – the GPs.

Yes, that feeling of unease has beencompletely replaced by a quiet

confidence that the theory that IT canimprove services and enable saferpatient care is not only true, but can bedelivered.

Last September the InformingHealthcare programme put itselfthrough a public international peerreview. Leading figures from healthcareinformatics in Holland, Denmark, NewZealand, Scotland, Finland, Canada andEngland were invited to critique Wales’approach. The encouraging results ofthis review, although published, werenever reported by the likes of e-HealthInsider or Private Eye.

Our confidence is largely due toGwyn Thomas (previous CEO of theNHSIA and UKCHIP board member),who became the IHC programmedirector in 2004. Gwyn’s quietunassuming style, complemented bysuperior leadership and influencingskills, has established relationships andbuilt trust. The effect has rippled downthrough the programme to the staff,who are in no small part responsiblefor our achievements.

This extends not only to those thatwork within IHC headquarters, but toall in the health informatics professionin Wales including the clinical, technicaland project management staffdistributed across the principality.

IHC has made efforts to link withlocal organisations by funding projectmanagers and support staff in everyhospital Trust. IHC has directlyengaged with many other clinical andtechnical staff who have contributed tothe programme with full support oftheir employing organisations.

From the start, InformingHealthcare has focused on serviceimprovement: it has invested in buildingrelationships with stakeholders,

‘What about Wales?’‘Wales? That’s in the south-westisn’t it?’

When I overheard that conversationabout five years ago, shortly beforeNPfIT and way before I was secondedinto the Informing Healthcare StrategyImplementation Programme (IHC), Iwas left with a strange feeling of disquiet. Of course, I am sure they didnot really think that Wales was part ofCornwall, rather assumed that Wales’IT strategy was somehow linked tosouth-west England’s electronic patientrecord procurement, but nevertheless itwas another example of Wales beingregarded as the backwater of the UK.

Wales has a completely devolvednational health service, which is onlydependent on Whitehall for itsallocation of UK funds. Devolutionmeans that Wales’ priorities aredifferent from England’s and this hasresulted in areas where care is better:for example, figures extracted from theCancer Information System Cymru(CanISC) have shown that Wales hasthe best lung cancer outcomes in theUK. The data that demonstrated thiswas so much more complete than thatfrom England that the figures wereinitially assumed to be a mistake.

I have not heard anyone say that we‘should be doing the same as England’for ages. Whilst media and politicalinterest across Offa’s Dyke havereached unprecedented levels for healthinformatics, Wales continues in its ownquiet and unassuming way, makingincremental and pragmatic progress ata pace many would regard asremarkable.

The Informing Healthcare strategywas only published in 2002 (four years

‘IHC’s clinical design

function bridges the gap

by gathering the raw

requirements from

clinicians and creating a

coherent and above all

safe design.’


13

The other unusual aspect of the IHCapproach is that of clinical design(okay, I admit that I am slightly biasedin this area): where clinical designersintercept and interpret userrequirements before they are handed totechnical developers. When there is noclinical design, technical solutions arelikely to be very specific to specific usergroups.

This is great in the specialty contextbut the solutions inevitably becomesilos of information that cannot supportthe patient journey through a modernhealthcare environment withmultidisciplinary teams and carenetworks. Healthcare is complex andindividual users rarely have a completegrasp of all areas. Likewise, technicalanalysts rarely have a completeunderstanding of the whole ofhealthcare, which is so important indeveloping national informationservices.

IHC’s clinical design functionbridges the gap by gathering the rawrequirements from clinicians andcreating a coherent and above all safedesign, represented in semi formalmodels that technical developers canwork to. This approach is proving to bevery positive: the design for the WelshClinical Portal has been widelyapproved by doctors, nurses,pharmacists and other healthcareprofessionals. The first version of theportal, with functionality to request

education and training, professionaldevelopment improving access to theknowledge base, project managementand organisation preparedness as muchas the development of new IT services.As a result, duplicate patient IDs inelectronic systems have been reducedfrom 4.6 per cent to 1.4 per cent, 15per cent of the workforce haveregistered on ECDL courses, the NHSe-library has doubled in size and theNHS has agreed an approach todeveloping a national technicalarchitecture, where the agreed positionis to do things ‘in common’ unless thereare clear benefits from doing thingsdifferently.

Local input sought

Informing Healthcare has actively supported local innovation and, throughits service improvement projects, IHChas learned: how a simple colour codingof ward patient lists can reduce average length of in-patient stay by twodays; how to get electronic discharge summaries to GPs; which informationthe public regard as really sensitive;what information is needed to supportunscheduled care and which onlinehealth services patients really want.This learning is now being channelledinto three main development areas:

The Individual Health Record willbe extended across Wales in out-of-hours care settings and furtherdevelopment will see it introduced intoother unscheduled care settings.

Patient access to services will bedeveloped further with projects toenable citizens of Wales to book GPappointments and order repeatprescriptions online. Access to serviceswill develop incrementally until citizensare able to access their own IndividualHealth Record.

The Welsh Clinical Portal willbecome the first major component ofthe new national architecture. Waleshas a strong history of in-housedevelopment and organisations haveagreed to release staff to help developthe new portal. It is being designedthrough a ‘user-centred design’approach, with front line staff fromorganisations across the country beinginvolved directly through designworkshops. This is a striking example ofthe patient-care centred approach thatIHC is taking.

tests and view existing records will bedeployed in two hospitals before theend of 2007.

So is this side of the valley reallythis green? There are of course greatchallenges still to come – anyone whoclaims this is easy is either ignorant ortrying to sell you something. But Walesis the country of myth and legend.Which of these will health informaticsin Wales turn out to be? Time will tell,but I’ve already decided: it will belegendary.

Robin Mann is head of clinical design forInforming Healthcare. He stopped practicing medicine in 2001 when heestablished, and then managed, the healthinformatics unit at the Royal College ofPhysicians of London. He was secondedto the Welsh Assembly Government towork with IHC in 2004 and took up substantive employment in 2005. He ison the UKCHIP’s Education, Trainingand Development committee andbecame a BCS member in 2006.

Arthur’s stone in Wales – is this side of the valley greener?


14

Health delivery and academia join forces

Assistive technology and smart home technology are important subjects for healthcare delivery andacademia in Northern Ireland. They are just one area among the many current projects and initiativesdescribed by Paul McCullagh of the University of Ulster and Paul Comac of the HSC ICT Training Group.

electronic health care records,appointment details and up-to-dateinformation to be available when andwhere it is needed and with moreemphasis on quality healthcare;

patients to have more informationabout the care being planned for themand that patients should not have towait as long for appointments, tests,diagnosis or other treatment.

Projects include GP ICT connectingall GP surgeries to the HSC networkfor secure internet access, email andthe roll out of electronic transfer ofpathology results from laboratory

As in other parts of the UK, the area ofICT in healthcare delivery is undergoingsignificant change in Northern Ireland.

On 9 March 2005, the Minister forHealth, Social Services and PublicSafety Angela Smith launched a 10-year development programme, backedby an additional investment of at least£95 million, with the intention ofdelivering new systems and technologyacross the Health & Social CareService (HSC).

The programme’s aims, whichmirror other regions of the UK, include:

new computer systems to link GPsto hospitals;

systems to all practices.A second project is the Health and

Care Number, replacing numeroushospital numbers with a new uniquepatient identifier. Electronic registrationat GP surgeries, GP systems, PASsystems will all utilise this number.

Thirdly, the Person CentredCommunity Information System(PCIS) aims to establish a singleintegrated community health and socialcare record for all patients and clientsin respect of community based services.In4tek’s PARIS system is the preferredoption based on experience gleaned bythe South East Belfast Trust.

An Electronic Prescribing andEligibility System (EPES) will also bedeveloped, installed and supported. Thecontract, worth £6.8 million over five years (awarded to Hewlett-Packard)will involve all community pharmacistswithin 24 months. A 2-d bar code onGP prescriptions containing all of theinformation on the prescription willthen be read in to pharmacy systems,and information will then be transferredelectronically to the Central ServicesAgency for checking and paymentpurposes. The project will reduce error,provide greater efficiency, reduce fraudand provide accurate prescribing ratestatistics.

A GP Payments Calculation andAnalysis System (PCAS) wasimplemented in March 2005. Diseaseprevalence statistics were calculated byusing data provided from each GPsystem and the PCAS system was usedto calculate the number of qualitypoints due to each GP practice underthe new contract.

A cervical screening system (usingthe Exeter System) for the purposes of


15

processing and compression in medicalimaging; surgical informatics;information and communicationstechnology in primary care; decisionsupport systems in clinical decisionmaking; telemedicine.

The HSC ICT Training Groupprovides a seminar programme fordissemination of important healthinformatics advances to the local sectorby local, national and internationalspeakers. Areas of interest include: telemedicine, and store and forwardreferrals; ICT in health and social care; hospital information systems; general practitioner systems; assistivetechnology, home monitoring and smarthomes; chronic health management forconditions such as diabetes andcoronary heart disease; data miningand decision support; eHealth andinformation to the patient; nursinginformatics; and health informaticseducation.

The seminar programme providessynchronous video-conferencing tooutlying hospitals, and provides a linkbetween academia and practice. DrVictor Patterson, a consultantneurologist at the Royal VictoriaHospital and co-editor of ‘Introductionto Telemedicine (second edition)’,routinely performs teleneurology aspart of his clinical practice.

An area which is important tohealthcare delivery and academia is theintroduction of assistive technology andsmart home technology. University ofUlster in collaboration with Dundalk’sInstitute of Technology have

call and recall was introduced, with theaim of electronic transfer of cervicalscreening data to practices. Phase twowill replace the cellular pathologysystems with a standard system alreadyoperating in the Belfast LinkLaboratories and will deliver acomplete, integrated, regional cellularpathology record.

An Electronic Referral ManagementSystem (ERMS) aims to reformoutpatient services and is designed toreduce waiting times for treatment.

In addition to the upgraded ICTinfrastructure, there has been majororganisational restructuring as a resultof a review of public administrationresulting in: one regional health andsocial services authority to manageperformance; seven primary care-ledcommissioning groups; and five healthtrusts (instead of the previous 18)providing the services.

Links with other groups

Health informatics interests are coordinated through the BCS HealthInformatics Forum. There are alsostrong links with the HealthcareInformatics Society of Ireland, withmany research papers presented at thisforum. A number of high-profile international research and knowledgetransfer meetings with a health informatics theme have been organisedin the last few years including:European Society for Engineering andMedicine (Belfast, May 2001), thirdEuropean Workshop on PersonalisedHealth, (Belfast Dec 04), InternationalConference on Smart HomesTechnology (Belfast, June 06).

In December 2004, The UlsterInstitute of eHealth (UIeH) waslaunched. This is a forum to promotecollaboration between academics at theUniversity of Ulster and professionsallied to health at Ulster Community &Hospitals Trust (now South EasternTrust).

The UIeH website providesinformation to the citizen on treatmentsassociated with pain and for the bettercontrol of type 2 diabetes, to promotebreastfeeding, and manage strokes.

The Queen’s University Belfast hostsa healthcare informatics researchgroup. Research topics include: digitalmicroscopy and machine vision incancer diagnosis and prognosis; signal

contributed to the design of a 12-unithousing pilot in Dundalk, to be readyfor occupation in 2007. The ‘Nestling’project was so-named to convey theconcept of having technologyunobtrusively ‘nestled’ into the homesand devices, even the fabrics, thatpeople wear.

The South Eastern Trust hascommissioned smart home technologyfrom Tunstall to provide support forchronic patients and has teamed upwith Nestling to provide cross bordercollaboration in this area.

The University of Ulster has beenawarded funding of over £250,000 tocarry out multi-disciplinary research ina new European funded project calledCogKnow. The project is focused onhelping to address some of theproblems faced by ageing people withearly signs of mild dementia.

The three-year project involves 11partners with a range of scientific andmedical expertise from across Europe,including organisations from Estonia,Malta, Scandinavia, Spain, France andNetherlands. The project is aimed athelping people to remember, maintainsocial contact, perform daily lifeactivities and enhance their feelings ofsafety.

The objective is to research andprototype a portable, easilyconfigurable device that is available tothose people with memory lapses andother symptoms of dementia andassociated disorders.

A further project, Di@l-log, allowsdoctors to monitor and track diabetespatients from home using intelligentspoken dialogue technologies which canrelay patient data directly to the clinicthrough telephone conversations. This isabout to proceed to a clinical trial.

References can be found on the BCSwebsite: www.bcs.org/hinow

‘The objective is to

research and prototype a

portable, easily

configurable device that is

available to those people

with memory lapses and

other symptoms of

dementia and

associated disorders.’


16

Standards open upborder crossing

England and Scotland are sharing information in some instances but they are still few and far between,according to Ken Robertson, clinical lead for IM&T in Scotland. He gave a presentation at HC2007 onwhere Scotland and England are already collaborating, future prospects and the necessity of standards.Helen Boddy reports.

allergies and updates – to his 2005 listas that is ‘now very much in thelandscape’.

The extent to which information isshared between England and Scotlandvaries. On demographics, Scotland hasan agreement in principle with NHSConnecting for Health that Englishpatients can use their NHS number inScotland and Scottish patients, theequivalent CHI number in England.There is no duplication because of theway the numbers are allocated.

‘However, that is as far as it goes,’said Ken. ‘Scotland is under somepressure to consider the use of theSpine service again, which may haveconsiderable advantage, but the devil willbe the detail, as they say. ’In Scottishgeneral practice, GPEX has in the pastallowed an exchange of an extract ofinformation from one practice toanother, according to Ken. The GP2GPsystem has now been used a little inScotland and he expects it to increase.

Scotland has just completed a pilotof the Document Scanning System(Docman) Transfer, which allows theexchange of scanned documents(bitmap images). ‘In the past there hasbeen a lot of talk about data exchangebut perhaps we should start withinformation exchange for care and thenmove onto data exchange, he said.

As the Requirement forAccreditation (RFA) process has beenscrapped, Scotland uses an advancedfunctionality programme to keepsuppliers up to speed with what isconsidered important, for examplecontributions to the Emergency CareSummary. Through the Scottish CareInformation (SCI) Gateway (a national

‘The reality is that there is very littleinformation being shared at themoment,’ said Ken Robertson. Even inScotland, which is a small place, passing information across boundariesof the different stakeholders is a complex business. Ken explained thatScotland has Community HealthPartnerships (CHPs) and within eachof those there are several GP practices.CHPs have boundaries, which oftenoverlap. Health boards have severalCHPs and several boards constitute aregion, of which there are three.

At the moment Ken believes UKcollaboration is an uneven game ‘withthe English elephant sitting on the blindScottish mouse’. Nevertheless hebelieves progress is being made.

The bottom line needed forinformation sharing has changed little,according to Ken, since he spoke at thesame conference in 2005, when his listof the bottom line for data sharing was:

GP records;Prescriptions;Data sets for:

benchmarking;clinical governance; WHO and other government purposes.

‘Prescriptions are one of the currenciesof the health service and it would benice if patients were able to encash prescriptions wherever in the UK theywere given them,’ he elaborated. ‘Andwe also need to be able to exchangeinformation to cover benchmarking andclinical governance (which of course isvery much to the fore).’

Ken added one more point –

system that integrates primary andsecondary care systems using familiarand highly secure internet technology)there are still exchanges across bordersfrom Dumfries to Carlisle, which Kenrates as ‘going fairly well’.

The Scottish way of joining upcommunity and GP information systemsis through procurement of theInformation for Primary andCommunity Care (IPACC) system. Atthe moment procurement is beingscoped to allow real collaborationbetween community and GP systems.

‘The Emergency Care Summary hasbeen rolled out across the country andnow Connecting for Health is copyingus,’ said Ken. It contains certain drugs,repeat prescriptions and allergies andcontact details. It works on the consentmodel – implied consent for extractionof information from general practicebut explicit at time of access, unless thepatient is unconscious, and that is


17

Information Standards Board, butmuch of its work is around messagingand high level auditing, which Kendescribed as ‘depressing’.

Scotland has been cited in thedevelopment of the common userinterface. ‘This is interesting, excitingand essential but we shall have to waitand see what emerges from it,’ said Ken.

The major Scottish vehicle fordelivering clinical information standardsis the generic clinical systems toolset.Scotland now has live substantiationsfor cancer and mental health.

Perhaps the biggest change in termsof standards in the NHS, according toKen, is the realisation thatconcentration just on SNOMED CT isnot enough.

‘The interest in HL7-CDA’ [HealthLevel Seven Clinical DocumentArchitecture] is encouraging because itdoes look as though we are going topay some attention to the richinformation that we have and if we canfile it in such a way that it is at leastreusable it and shareable,’ he said. ‘Ithink there is real scope forcollaboration across the UK in thisarea’

HL7 is one of several StandardsDeveloping Organizations accredited byAmerican National Standards Institute(ANSI) that operate in the healthcarearena.

On SNOMED CT Ken hoped that

heavily audited. ‘I think that less than100 out of 5 million patients haveopted out of it,’ said Ken whenquestioned.

Moving onto the impact of thebusiness model and payment by results,Ken claimed it is not helpingcollaboration because of putting toomuch emphasis on bean counting. Froma clinical perspective, the lack of clarityaround what is happening with the carerecord service makes it difficult for usto collaborate properly.

In terms of drugs, Scotland likeEngland has been piloting electronictransfer of prescriptions (ETP) andhospital electronic prescribing andmedicine administration (HEPMA)systems. Scotland is in the process ofrefining requirements for HEPMA andwill go the market for a pan-ScotlandHEPMA system. Scotland is alsoprocuring a system to supportchemotherapy.

‘I know these are being paralleledsouth of the border but there isn’treally any great effort to align thatwork, Ken said. ‘But we are aligned onthe Dictionary of Medicines andDevices.’

On clinical data standards, Ken saidthat Scotland has 45 clinical standards,which are extensive, and a health andsocial care dictionary with more than3000 items.

Scotland is represented on the NHS

something would happen to solveimplementation issues. ‘At some pointwe are actually going to decide we aregoing to eat this elephant because wehave to convert, especially in primarycare, a huge amount of data, and that’snot going to be a small task,’ he said.

In conclusion, Ken said: ‘I think it isabundantly clear that we are not goingto have the same systems, but we mighthave some the same. We will thereforebe dependent on standards. I thinkthere is no doubt that we couldcollaborate better across the UK, butthe hard bit is that a great deal ofcommon sense is required to do so.

‘I think that it’s time that theclinical community takes ownership ofthis problem. I genuinely don’t believethat the technical architects can help usunless we give them a clear steer ofwhat we need. In this regard, I thinkthere is a clear role for the professionalbodies who will also be involved inhelping to mandate standards.’


18

Knowledge shared isknowledge doubled

Improving eHealth knowledge can release precious clinician time, ultimately improving patient care.NHS Education for Scotland is therefore setting up an eHealth knowledge sharing tool for NMAHPs inthe form of an e-Library. Kathy Dallest and Ann Wales from NHS Education of Scotland explain.

clinical, education, business, healthinformatics and KM domains are beingemployed. Improving knowledge andunderstanding and focusing on thebenefits of eHealth can release preciousclinician time to deliver positiveoutcomes for practitioners. Ultimatelythis improves the patient experience,quality of care and increases patientsafety. This project offers substantialbenefits through sustainability, and themethodology will be transferable to othersettings and professional groups. It isan important step towards supportingall clinicians involved in eHealth.

Purpose and objectives

Essentially this is a change managementproject which aims to create an environment where knowledge, experience and information can beshared, created and accessed in orderto support NMAHPs at various levelsof interaction within the eHealthdomain. The goal of the project is toembed these aspects of quality information management and informatics practice into NMAHP clinical and professional practice.

The objectives are: to supportclinical engagement necessary to realisethe benefits offered by the eHealthstrategy and its programmes; toactively facilitate learning, developmentand sharing of information and bestpractice, including use ofcommunication functionality on the e-Library; to manage the informationresources used by the communities ofpractice; to identify and provide accessto the existing knowledge base onNMAHP eHealth; and to develop andcreate new information resources.

The sharing of information surroundingthe actual benefits of eHealth is patchyand rarely managed by nurses, midwives and allied health professions(NMAHP). This often leads to inadequately defined requirements foreHealth systems and the consequentlack of uptake by NMAHPs.

Yet real and tangible involvement ofinformed frontline healthcarepractitioners in the specification, designand implementation of health ICTsystems has been called for in therecent Audit Scotland report, ‘Informedto Care’, and various others.

To address the critical gap inawareness and information sharing, theKnowledge Services Group within NHSEducation for Scotland has beencommissioned by the Scottish ExecutiveHealth Department to deliver solutionsto facilitate development of anNMAHP eHealth Managed KnowledgeNetwork (MKN). A dedicated special e-Library (or portal) will be createdwithin the NHS Scotland e-Library(www.elib.scot.nhs.uk), incorporatingcommunication, information resourcemanagement and retrieval functionality.eHealth is defined, for the scope of thisproject, as ‘…the application of ICT tosupport healthcare provision’.

This project builds upon the existingNMAHP eHealth ‘Shared Space’, acollaborative workspace employingelectronic communication andinformation resource managementtools. Building upon previous lessonslearned, this project is an extension ofeHealth knowledge management (KM)across all NMAHP disciplines, and isdesigned to facilitate engagement andleadership development.

Blended methodologies from the

Network and communication

Some early network members are clinical leaders, influential in nationaland local strategic business and development plans. Some have a specific eHealth job within informationor IM&T departments and directly support system implementation. Othersare clinical practitioners who regularlyuse technology.The network also supports practitioners new toeHealth/informatics. The 105-membernetwork collectively manages its information resources, communicatingthrough the Shared Space (URL at endand see screenshot opposite).

NMAHP eHealth is home to sixdiscrete communities of practice andproject groups, one of which is theNMAHP eHealth leads. Each nurse andAHP director from every NHS board inScotland (14 of them) has sponsored alead for eHealth in each of acutenursing, midwifery, the allied healthprofessions and primary and communitycare and mental health areas. Thesepeople support Heather Strachan, theeHealth lead for NMAHPs withinSEHD, to deliver a portfolio of projectsaimed at maximising benefits offered bythe National eHealth Programme.Communication within this communityis multidirectional and transcendsorganisational and role boundaries.

The NMAHP eHealth special e-Library, which incorporates andbuilds on the existing Shared Space,will be a dedicated portal that providesfocused and targeted informationresources specific to the needs of theMKN. It will provide access to all thee-Library services, such as NHS Scotlandfulltext online journals (over 5,000),


19

focused implementation plan for theMKN. Evaluations so far have beenpositive.

Additionally an online questionnairegathers information on relevant contentsuch as journals and other publishedsources as well as information seekingbehaviours. Another will gather selfassessment data about KMcompetencies. This will be fed back tothe participants and also informs theMKN’s future plans.

A robust communication planensures communications reach thecommunity that the project needs toengage via: a leaflet; messages at allCPD activities at key events; aconference poster for the NHSScotland event; a bi-monthly electronicnewsletter; and a communications packfor the MKN launch in November.

Membership of the Shared Space,since its introduction to the NMAHPeHealth community in October 2006,has increased to 105. The number ofvisitors increased month-on-month to185 in March. Activity rose to 4,365hits in March, with visits to more areasof the site. Resources are now beingadded by the membership andknowledge exchange through discussionis increasing.

The Shared Space is growingorganically with members contributing

bibliographic databases and otherinformation resources. Additionally,information relevant to this domain willbe filtered and organised in ways thathelp NMAHPs find what they arelooking for, such as via appropriatesubject headings. Federated searchtechnology will be used to retrieveinformation from remote sources, andfurther functionality will be developed.

The project team is currentlyundertaking an information andknowledge audit with key stakeholders,analysing information flows, sources,needs, user characteristics and gaps.The audit also includes a KMcompetency training needs analysis. Thiswill inform the technical specificationand information content for the speciale-Library and future plans.

Given the short timeframe, and thedemands on clinical resource, a novelapproach to requirements gathering forthe portal construction has been taken.The project team is delivering a KMCPD package that maps to theKnowledge and Skills Framework(KSF) Information and KnowledgeDimensions 1 and 3 at Level 4. Thedata and information outputs of thevarious learning exercises within thepackage are being analysed to informthe specification for the portal, anddevelop a KM strategy and outcome-

to the knowledge base. Thefacilitator adds relevant news,resources and discussion topics.There is realistic optimism that thiswill be a collaborative andknowledge sharing tool with thedevelopment of the special e-Library – to be launched on 6November at the Scottish ClinicalInformation Management inPractice (SCIMP) conference.

Getting involved is easy and anyonewith an interest can join the NMAHPeHealth Shared Space at:www.elib.scot.nhs.uk/SharedSpace/nmahp/Pages/login.aspx

Kathy Dallest is a nurse informaticianand presently MKN facilitator, Knowledge Services Group, and AnnWales is programme director forknowledge management. Contact: [email protected]

NMAHP eHealth Shared Space homepage


20

Are we nearlythere yet?ICT bringing services closer to the patient is what modernisationshould be about, believes Keith Clough. In this article, he takes alook at lessons from the past and considers whether we are anycloser now to the destination.

RHA had a regional computing unit(RCU) with at least 100 staff – somehad more than 200. Each RCU had acapability to write, run and installcomputer applications – such as PAS,pathology, child health and financialsystems. Furthermore, some regionswrote and even ran applications forother regions.

We worked as though there was a‘national’ health service. We evenworked closely with our colleagues inWales, Scotland and Northern Irelandand with those employed by theDepartment of Health.

Our shared wisdom at the time –based on some successes (and a fewfailures) – had reached several‘conclusions’.

Here, in no particular order, are 12 ofthem:

The most important issue isimplementation since it involves many,already over-worked individuals from anumber of different professions (andpossibly different organisations).

The rate of implementation roll-outis more dependent on the healthauthority’s willingness and capabilitythan to any capital budget constraints.

Maintaining the interest andenthusiasm of users is vital for asuccessful implementation.

It is essential to involve users at allstages – specification of requirements,procurement, implementation, liverunning and subsequent modification.

Both user and managementexpectations should be managed.

Delivery of an application or a usablesub-set should, ideally, be within sixmonths – otherwise the users looseinterest.

‘Are we nearly there yet?’ is the question often asked by the smallerpassengers on the back seat of the car.They probably have only a vague ideaof the intended destination and had no(or very limited) input to its choice.They were probably given no option asto whether they wanted to go on thejourney and may even have had otherthings that they would have preferredto do. However, based on past experience, they probably have confidence that the driver knows wherethey are going and how to get there.They may have concerns that the driverdoes not usually welcome advice (oreven stop to re-visit the map) when lost.

Do you see any similarities inrespect of the current plans for IT inthe NHS in England? Do we hearclinicians (and some managers) askingthe question ‘Are we nearly there, yet?’What about their confidence based onpast experience?

What’s changed in 20 years?

Many of us who were working in NHScomputing 20 years ago thought thenthat we were nearly there. Most hospitals had some computer systemsworking and nearly all GP surgerieswere computerised. The only thing needed – we thought – was for thesesystems to communicate with eachother. Once that had been achieved, anumber of other things would be possible, including changes to the wayhealthcare was delivered and where itwas provided. The ‘C’ was to be themost important letter in ICT.

Where did we get it wrong? A fewof you may remember that in the late1980s, the NHS had 14 regional healthauthorities (RHA) in England. Each

It is extremely difficult and usuallyvery costly to anglicise an applicationwritten for the American market.

When offered a ‘working’ system,insist on trying it yourself –demonstrations are easy to fake.

The importance of the procurementprocess is often overrated. Many healthauthorities got good results from poorsystems and some got poor results fromgood systems. The local implementationis the most important factor.


21

Most staff at the Department ofHealth have a very limited knowledgeof how the NHS is managed and howhealthcare is delivered.

The power of the medical mafiashould not be underestimated. There isoften more than one and each has itsown agenda.

If it ain’t broke, don’t try to fix it.

Are any of these conclusions still validtoday? If so, are they recognised asconstraints by those in the driving seat?As far as I can remember, the needs ofthe patient and their lay carers was nota prime consideration.

As we were working for RHAs, wehad only a limited knowledge of whatwas happening in the computerisationof primary care or, to be moreaccurate, GP surgeries. Only later, whenI became involved in telemedicine, did Irealise the communications gulfbetween those working in the primarycare sector and those working insecondary care.

In my view, ICT starts to make a

real impact on modernising healthcaredelivery when patient information istransmitted rather than, for example,

the patient having to visit or stay in thehospital for tests. Any subsequentnecessary treatment can then often beadministered at the surgery or even inthe patient’s home. There are already

many examples of ICT being used inthis modernisation process bringingservices closer to the patient.Unfortunately these techniques,although demonstrated locally, have notbeen widely implemented as they arethought to be post-NPfIT.

Hence, the answer to the originalquestion must be an emphatic ‘no’. Butthen, because of medical developmentsand changes in how healthcare isprovided, the destination is not fixedand the answer will always be no.

However, it may be possible toreduce the journey time – especially ifwe can cut out some of the detourswhich provide little or no benefit topatients or clinicians. Is it time to re-visit the map, review the destinationand even get the views of the cliniciansand patients?

Keith Clough is co-ordinator of The e-Health Innovation andProfessionals Group and treasurer anddeputy chairman of the BCS HealthInformatics Interactive Care specialistgroup.

‘ICT starts to make a

real impact on

modernising healthcare

delivery when patient

information is

transmitted rather

than the patient

having to visit.’

The outstanding contribution to healthinformatics by Glyn Hayes, chair ofBCS Health of Informatics Forum(BCSHIF), was recognised with a special award at this year’s HealthcareComputing (HC2007) conference.

‘Glyn has been a major influence inlooking at GP computing in the UK,’said Prof Stephen Kay, chairman of theHC conference programme committee.‘The award is in recognition of hislifelong achievement in healthinformatics, his sustained leadership inthe discipline and his promotion ofprofessional standards.’

From early in his career as a GP inthe 1970s, Glyn became involved in thedevelopment of GP systems. He wasalso a founder member of the BCSPrimary Health Care Specialist Group,was later chair and is now its president.He is also president of UK Council forHealth Informatics Profession, and ison the executive and programmecommittee for HC.

Ian Herbert, vice president ofBCSHIF received the award on behalf

Glyn Hayes receives special accolade

of Glyn, who was not able to attend theconference because of ill health. ‘Thisplace [HC] is not the same withoutGlyn,’ said Ian. ‘I know he will be verypleased to receive this honour.’

Ian Herbert (right), BCSHIF vice chair,

accepting the award on Glyn’s behalf

(pictured right), from Prof. Stephen Kay


22

S C O T L A N D S P E C I A L I S T G R O U P

Meet the Specialist Groups

ScotlandSpecialist groups are the grass roots of BCSHIF. Introducing the work of a group is a regular feature in‘Health Informatics Now’. This article focuses on the work and activities of the BCS Health Informatics(Scotland) Group (HIS), written by its chair Charles Doherty.

BCS HIS is a multi-professional groupthat aims to promote the developmentand use of health informatics inScotland to support effective, evidencebased, efficient health and social care.This is intended to benefit the health ofindividuals, communities, and populationsthat receive health and social care andthe staff and organisations that deliverthese services.

The group is a long-standing memberof the BCS Health Informatics Forum(BCSHIF) but became dormant whenits most active member and leader, RayJones, left Scotland for warmer climes(Plymouth). In 2003, spurred byBCSHIF chair, Glyn Hayes, a group metwith the aim of re-establishing the BCSHealth Informatics presence inScotland. This group gained the supportof stalwarts of the health informaticsscene in Scotland such as John Brydon,Derek Hoy, Sue Kinn, and Kathy Dallestand was led by Heather Strachan.

After some hard work re-writing theconstitution and terms of reference,successfully organising meetings anddisseminating information about thegroup, the corner has been turned andthe membership is again beginning togrow: it currently stands at 222. Thecommittee has now been reconstitutedand poised to build on a solid foundation.

Objectives

Firstly, the group aims to representScotland’s health informatics communityon national and international groups topromote and influence the developmentand direction of health informatics. Wealready have representation in manyimportant organisations and fora in

Scotland, the UK and beyond. We arethus in a good position to achieve oursecond and third objectives – to promote the sharing of good practiceacross our constituency, the Scottishhealth informatics community, agenciesand organisations; and to provide aScottish health informatics perspectivewithin Scottish and UK developmentsin health and social care.

Finally, we aspire to act as aconsultation mechanism for relevantnational and international projects,policies and standards on healthinformatics and to initiate healthinformatics projects with appropriatepartners. This is beginning to happen,but we have yet to fulfill this objectiveto our potential.

Activities

These are geared towards our aims andobjectives, and revolve around meetings, communications and conference organisation to promotehealth informatics nationally. For eachof the past three years, we have organised a national health informaticsconference.

The first, at Glasgow CaledonianUniversity in 2004, attracted 50delegates, and focused on currentdevelopments in health informatics. Thenext, in 2005 was located in Dunblane,attracted over 60 delegates, and focusedon information governance from multipleperspectives. There were excellentpresentations from a clinical perspectiveby the national lead for eHealth; legaland law-enforcement perspectives from alawyer and police officer; complementedwith social work and education

perspectives. The issues around sharinginformation from these strikinglydifferent paradigms led to an interestingand lively debate.

Our latest conference, eBrochan inNovember 2006, in collaboration withBSC HI (Nursing) specialist groupagain was excellent, our best yet, andattracted over 70 delegates. The fullconference report is in the Marchedition of Health Informatics Now. Ourprofile as a group and our reputationfor being able to network and organisenationally important conferences is atan all-time high.

In the forthcoming year ournational conference is on November 23,again in Glasgow Caledonian University.The focus is as yet undecided, but thereare enough exciting developments tocreate a diverse and interestingprogramme. Watch this space. We alsoplan to test demand for more frequentsmall-scale events, and, for the firsttime, we aim to organise a session atHC2008.

Our website is now in expert handsand we look forward to developments,perhaps moving towards a site with moreof a community network philosophyrather than the current static web pages.This interactive mechanism could betterserve the needs of our growingmembership who currently only receiveperiodic newsletters and email bulletinsas issues arise. Being more responsive toour membership’s needs and to engagethem in the organisation and running ofthe group is a challenge to all specialistgroups as we are run on a voluntarybasis. The mechanisms for doing this asyet are not entirely clear, but we areworking on it.


23

Chair, Dr Charles Docherty

Charles is a senior lecturer in practice-based learning at Glasgow CaledonianUniversity. He teaches eHealth to pre-and post-graduate students and for twoyears has organised and delivered ahealth informatics elective for nursingPhD students in Jordan. He representshis university on the InternationalMedical Informatics Association, theBCS nursing specialist group onConnecting for Health’s national advisory group, and is an organisingcommittee member of the Associationof Common European NursingDiagnoses, Interventions and Outcomes.He represents BCS HIS on theNational eHealth NMAHP clinicalleads group in Scotland. His PhD is inthe educational use of multimedia.

Vice chair, Lachlan MacPherson

Lachlan is a capacity planning managerin a remote and rural health board inthe Western Isles. He has responsibilityfor emergency planning and medicalrewards. His background is in electronicengineering and he has an MSc inOperational Research.

Treasurer, Dr Sue Kinn

Sue is currently a civil servant, workingin the Department for InternationalDevelopment where she manages a programme of research in health andeducation in developing countries.Previously Sue was a health servicesresearcher with interests in the involvement of patients and members ofthe public in health research, publichealth and health informatics. Sue hasalso worked in the NHS in clinicalaudit and as a computer specialist. Sueoriginally trained as a cell biologist andworked as a laboratory researcher forseveral years.

Co-treasurer, Fiona Black

Fiona has worked for NHS NationalServices Scotland Information ServicesDivision (ISD) for six years, in a variety of information development

Who’s who on the committee

roles. She is currently information governance development manager forISD’s information governance programme. She has an MSc in healthinformatics.

Secretary, Praveena Oliphant

Praveena is currently the patient information manager, Cancer andPalliative Care Information Service atDykebar Hospital in Paisley

Webmaster, Kathryn Trinder

Kathy is a learning technologist atGlasgow Caledonian University. She hasan MSc in eLearning, and is currently alecturer and research fellow in e-learingwith the Caledonian Academy.

Committee members

Derek Hoy is a research fellow in theResearch Centre for Nursing, Midwiferyand Community Health, GlasgowCaledonian University.

Derek’s recent projects haveincluded WISECARE, networkingoncology nurses round Europe,knowledge mapping and topic mappingsystems for NHS Scotland; andCommunity Information Standardswork for NHS Scotland. He currentlyrepresents BCS HIS on ScottishClinical Information Management inPractice (SCIMP).

Kerr Donaldson is project manager,Scottish Social Care Data StandardsProject.

Wendy Dungavel is an eHealth trainerat Beatson Oncology Centre, Glasgow.

Raymond Duffy is a lecturer withdegrees in biology, health promotion andeducation. He works at the University ofPaisley, where his main role is indelivering post registration education.Specialising in online learning as an e-tutor for a gerontological nursingprogramme, he has been involved inwriting and editing support materials formodules and courses designed to bedelivered online.

Co-opted members:

Colin Brown, SCIMP Moira McLaughlin, EHRIM Sharon Levy, RCN Heather Strachan

Heather recently stepped down as chairof BCS HIS but retains a co-opted position on the group to provide a directlink with the Scottish Executive HealthDepartment as the eHealth lead for nursing, midwifery and allied health professions. Heather’s various previousposts have involved management, practicedevelopment, research and healthcaregovernance. She is an honorary memberof the International Medical InformaticsAssociation special interest group onnursing informatics.

From left to right: Charles Docherty, Kathy Dallest, Lachlan MacPherson,

Heather Strachan, Kerr Donaldson


24

N O R T H E R N S P E C I A L I S T G R O U P

Dutch share experience of decision-making systems

Clinical decision support systems which will advise clinicians on providing the best treatment forpatients are slated to be introduced in the UK in 2009-2010. A talk by Dr François Dupuits from theNetherlands to the Nothern Specalist Group highlighted useful lessons from a county where they arealready in use, writes the group’s chair Tom Sharpe, based on a meeting report by Phil Paterson.

Clinical decision support systems(CDSS) provide direct advice and assistance to clinicians to help themprovide the best treatment for patients.Leading experts have presented cogentarguments for their introduction. Up to97,000 deaths per year were attributedto medical errors in the US, accordingto Professor John Fox who gave a previous talk to this group. Dr JeremyRogers estimated that only 70 per centof acute patients received appropriatetreatment. Professor Alan Rector saidthat the complexity and rate of growthof medical knowledge is such that (evidence-based) medicine is now a‘humanly impossible task’.

CDSS could make a real impact inhelping to address these issues.Professor Fox showed how the efficacyof a decision support systemintervention compared favourably withthat of a powerful prescription drug.

CDSS were included as a part ofphase 3 of the National Programme forIT and slated for introduction as earlyas 2009-2010. Although there is astrong research base in the UK, thetheory and transfer into practice ofCDSS are notoriously difficult areas,and it will be interesting to see howmuch can be up and running in thatsort of timescale. Meanwhile, it isuseful to see what we can learn fromexperience with practical use of CDSSin other countries.

Lessons from The Netherlands

Dr François Dupuits is a researcher

with over 20 years’ experience in medicaldecision support in the Department ofFamily Medicine at Maastricht


25

University in The Netherlands. Afterpresenting a paper at HC2007, DrDupuits agreed to come to Manchesterand talk about his experiences to theNorthern SG before returning to theNetherlands. The rest of this articlehighlights some of the points raised inhis talk and the ensuing discussion.

CDSS support humans in making achoice – the user often has to giveadditional information to the decisionsupport system and make a choice fromthe resultant options offered. They aredifferent both from information systems(which present data) and from expertsystems (which offer a ‘best’ solutionbut do not provide interaction).

There are two types of CDSS –passive and active. Passive CDSSmerely present relevant knowledge tothe user. Active CDSS combine datainput by the user with knowledge builtinto the system to come up with anoverview of possible decisions for theuser to select from.

The three fundamental componentsof CDSS are: the data base, theknowledge base and the dialogue andmanagement software. The databasecontains patient details. The knowledgebase contains the standards andguidelines. The dialogue andmanagement software guides theprocess of selecting decision options forconsideration and then presenting theseoptions to the user.

An innovative phased developmentmethod was used to create applicationsat Maastricht. Careful evaluation ofthese systems was carried out all stagesof development. Although severalapplications including a number ofCDSS have been developed, there wasonly time for Dr Dupuits to cover twoof them in his talk.

The BODE and eXPert system isbased on six clinically-orientedinformation sheets related to a patient,covering signs/symptoms, physicalexamination, diagnoses, known diseases,medication and medical test requests.Dr Dupuits showed examples of theseinformation sheets and described howthey are used in practice.

The aim of the ‘Quality of Life’(QoL) system is to advise adultsconcerning their quality of life and wayof living. It can be used not only bypatients but also by carers, helpingthem make the right decisions on thecare they should provide to their

patients. It can also be used to enableresearchers to study the quality of lifeof these adults and the impacts ofdiseases on this quality.

Discussion

One of the problems of CDSS in generalpractice in the UK is that there isn’ttime for a busy GP to use them. This isrelated to the problem of using a keyboard to enter data into a computer.It is possible that the amount of inputcan be reduced by careful structuringof questions, and alternatives to thekeyboard can be found.

CDSS must be safe. In one year’stime the Maastricht team expect tohave a system that will present testsand drugs and available standards andwill advise on their use. All thepositives are included now, which filterout ‘rubbish’, but not yet the warnings –these will come later in a separate partof the system.

Another known problem is thatCDSS don’t work very well when youtry to introduce them more widely, ortransfer them from one geographicalregion to another. The Maastrichtsystem is already in use throughout oneprovince, and it has been successfullytransferred to another province, so thisneed not always be true.

Knowledge has to be kept up-to-date and be continuously monitored. Inthe Maastricht project, this is done by a

Dr François Dupuits

Quality Circle, a panel of experts on atopic like diabetes which meetsregularly (referring to a larger panelwhere necessary) and produces monthlyupdates to the knowledge base. In theUK, the data collected in the NHS CareRecords Service could be of immensevalue in building or validatingknowledge bases, but human expertisewill still be required.

Conclusions

CDSS can provide many benefits. Thework in The Netherlands has shownimproved correctness, better diagnoses,and a growing effect on medical practice. CDSS can also result in costsavings as health professionals workmore to standards and more rationaldecision making, avoiding unnecessarytests.

There are a few caveats. CDSS areonly successful when users are involvedin their life cycle. They should only beused as a tool in supporting decisionmaking: users appreciate the freedomto follow or reject the advice given. Theunderlying knowledge base must becapable of being continuously updated,and the decision-making process mustbe open to inspection. Although thesystems discussed are essentially stand-alone, integration with medicalinformation systems is preferable in time.

No doubt we shall be seeing a lotmore of them in the future.


26

NPfIT: the inside story

to the government’s Health SelectCommittee. The theme that came overwas that in the eyes of the suppliers thenational programme is maturing andthe mood is positive.

By the time Health InformaticsNow is printed, we will have had ourlast NPfIT meeting of the academicyear. Andrew Spence, healthcarestrategy director at CSC, local serviceprovider (LSP) for three of the fiveclusters is due to describe how the roleof the LSP has evolved over the lastthree years and how it might continueto evolve in the future, how the LSPsadd value and how CSC approaches thedelivery and support tasks.

As mentioned previously, we can’tgo into details of the content of thetalks, but the overall message has beenpretty upbeat. Whilst there is alwaysgoing to be a certain amount of positivespin on the delivery of NPfIT, in ouropinion the fact that insiders areprepared to put their heads above theparapet and speak openly about theissues involved is significant in itself. Itsays a lot more both about the state ofthe Programme and the relationshipbetween NHS Connecting for Healthand the BCS than some of the morenegative messages that have been sentout recently.

Where else but the BCS can peopleget such a breadth of vision of how IT isdeveloping in the NHS and speak withoutfear or restriction to some of the topmovers and shakers who are influencingprogress from their different positions?The only way to catch those off-the-record remarks and get the inside story isto come along to our meetings.

The most popular meetings over the lastthree years have undoubtedly been thoserelated to the National Programme forIT (NPfIT) in the NHS, where ourspeakers have presented very well-informed and interesting talks from arange of different viewpoints.

Not too surprisingly, most speakerson NPfIT ask for confidentiality withinthe audience, which allows them to airtheir views and answer questions openlyin a non-threatening, neutral,professional environment which benefitsthe speakers and the questioners in theaudience. The downside of this is thatwe cannot give much post-eventpublicity to who said what in case theirposition is compromised as a result.

Conversely, our speakers in the less‘political’ areas of health informaticsare usually delighted to get extrapublicity through vehicles such asHealth Informatics Now, which allowsus to contribute to the magazine on aregular basis. In this issue we arefocusing on decision support in medicinebut, lest we forget, I would like tohighlight the fascinating talks we haveenjoyed on NPfIT so far in 2006-7.

We started off in October with anirreverent talk from industry expert

Phil Sissons on ‘Things you didn’t wantto know about NPfIT’, which examinedsome of the options and choices – rightand wrong – that were made in theearly days of the programme. This wasquickly followed in November by PaulCharnley, regional implementationdirector for the North West and WestMidlands cluster, enlightening us onhow things are going in our region andhow key issues are being addressed.

Moving into 2007, in February weheard all about the PACS success storyfrom Dr Rhidian Bramley, consultantradiologist and national clinical advisorto the PACS Programme and in Marchwe heard the ‘clinicians’ view’ of thenational programme from ProfessorMike Pringle, a national clinical leadfor GPs, with emphasis on theSummary Care Record and clinicalgovernance arrangements.

In between, we had organised asession at the Healthcare Computing2007 conference in Harrogate at whichJeremy Nettle, the new chair of theIntellect Healthcare Council, presentedthe IT industry’s response to theimpact of NPfIT on the market,bringing out some of the issues involvedand summarising current progressbefore reflecting on Intellect’s response

The BCS HI (Northern) Group arranges an eclectic programme of lectures each year, covering differentdisciplines with speakers from widely differing backgrounds. The audiences are correspondingly variedin terms of both the types of people who attend and the numbers. In this article, Phil Paterson andTom Sharpe of the group give an overview of the talks that related to the National Programme for IT.

N O R T H E R N S P E C I A L I S T G R O U P

Paul Charnley

Phil Sissons


Forthcoming events

27

June

ASSIST North West BranchPACS site visit, preceded by AGM20 June. 2.30-5pmCountess of Chester Hospital, Chester http://northwest.assist.org.uk

ASSIST West Midlands Branch 27 June 2007. 10am-3pmBranch AGM and Microsoft – common user interface; NHSWARP – neighbourhood watch for NHS IT security, Fujitsu – NHS service desk, CfH social care integrationTrinity Park near Birmingham NECwww.assist.org.uk/branches/Westmids/Index.htm

Interactive Care Specialist GroupSpeaker to be confirmed28 June. 6pmBCS, 5 Southampton Street, London, WC2E 7HA and interactive teleconferencewww.hiicsg.bcs.org/events.htm

July

Health Informatics Forum seminar10 July. 12.30pm for 1.30pmBCS, 5 Southampton Street, London, WC2E 7HATo reserve your place, email: [email protected]

London and South East Specialist Group19 July. 5.30pm (refreshments) for 6pm Update on London programme Presenter: Kevin JarroldBCS, 5 Southampton Street, London, WC2E 7HAwww.hilsesg.bcs.org/fevents.htm

September

ASSIST North West BranchInformatics and the 18 week wait – follow up workshop11 September, 1.30pmWrightington Conference Centrehttp://northwest.assist.org.uk

Northern Specialist GroupConnecting for Health: ‘The Road not Taken’Presenter: Prof Rajan Madhok26 September. 6.15 for 7pm Manchester Conference Centre, University of Manchester,Sackville Street Campus, Manchester, M1 3BB www.bcs-nmsg.org.uk

Primary Health Care Specialist GroupAnnual conferenceGlobal health records – putting the patient at the heart of care28-29 SeptemberEynsham Hall, Oxfordshirewww.phcsg.org.uk

London and South East Specialist Group27 September. 5.30pm (refreshments) for 6pm Speaker to be confirmedBCS, 5 Southampton Street, Londonwww.hilsesg.bcs.org/fevents.htm

October

ASSIST North West BranchSNOMED CT Pilot4 October. 3 pmNeurosciences Lecture Theatre, Salford Royal HospitalsFoundation Trusthttp://northwest.assist.org.uk

ASSIST North West Branchwith the NHS North West Strategic Health Authority One-day event in w/c 8 October http://northwest.assist.org.uk

Health Informatics Forum seminar2 October. 12.30pm for 1.30pm. End: 4pmBCS, 5 Southampton Street, London, WC2E 7HATo reserve your place, email: [email protected]

November

Northern Specialist Group15 November. 6.15 for 7pm. NHS Connecting For Health – The Nurses’ View Presenter: Barbara StuttleManchester Conference Centre, University of Manchesterwww.bcs-nmsg.org.uk

London and South East Specialist Group22 November. 5.30pm (refreshments) for 6pm Speaker to be confirmedBCS, 5 Southampton Street, Londonwww.hilsesg.bcs.org/fevents.htm

Scotland Specialist GroupConference23 NovemberGlasgow Caledonian Universitywww.scotshi.bcs.org.uk/Events.htm


Interactive Care: www.hiicsg.bcs.orgLondon and South East: www.hilsesg.bcs.orgNorthern: www.bcs-nmsg.org.ukNursing: www.bcsnsg.org.ukPrimary Health Care: www.phcsg.org.ukScotland: www.scotshi.bcs.org.ukASSIST: www.assist.org.ukBCS Health Informatics Forum: www.bcshif.org


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