After the General Election in 1997, the Labour Government commenced implementation of its pledge to modernise the National Health Service. Early assessments showed the important role that information technology (IT) would play in a modern NHS. In September 1998 the NHS Executive published Information for Health: An Information Strategy for the Modern NHS 1998–2005.1 The document laid out how the focus must change from a culture where IT systems were used for collecting financial data to one where they are used to facilitate patient care.
The basis of the strategy was a commitment to develop:
- Lifelong electronic health records for every person in the country
- Round-the-clock online access to patient records and information about best clinical practice for all NHS clinicians
- Genuine seamless care for patients through GPs, hospitals and community services sharing information across the internet
- Fast and convenient public access to information and care through online information services and telemedicine
- Effective use of NHS resources by the provision of health planners and managers with the information they need.
In January 2001 the NHS Executive published Building the Information Core – Implementing the NHS Plan.2 If anyone is in any doubt as to the Government's commitment to modernising IT in the NHS, the summary of additional investment gives a simple answer:
- In the past 2 years an additional £214 million has been provided to support the modernisation of NHS information systems
- Over the next 3 years an additional £533 million will be provided for IM&T investment
- The cost of providing NHSnet, with email and web-browsing facilities, to every GP's desktop will be in excess of £400 million.
Implications for general practice
The NHS records a vast amount of clinical information about patients. Until recently, this was largely manually recorded.
Recording data electronically has many advantages but also some disadvantages. The advantages include the storage space required, the ability to search in a fraction of the time that it would take to search the same data manually and the ability to copy and transmit the data electronically.
The GP, the community nurse, the hospital and Social Services currently make up a number of 'data islands'. These individual data islands each build up a separate database of health information about a person, in which much information is duplicated but little is shared. Some important information, therefore, may not be shared.
The ideal for the patient and the clinician is to eliminate duplication and make important clinical information readily available, mindful of all the issues of informed consent and security of information.To achieve this free information flow, all the data islands need to communicate effectively with each other and then be able to transfer electronic data.
NHSnet is a secure network for the NHS that enables the process of connecting the data islands and establishing flows of information between GPs, community staff and hospitals.
It was therefore fundamental to establish NHSnet before any other major development could take place. A timetable of staged development has been laid out in the document Building the Information Core – Implementing the NHS Plan.2
The following commitments are part of the modernisation agenda for the NHS:
- By March 2001:
- 98% of general practices to be computerised
- 95% of general practices and 25% of trust clinical staff to have an NHSnet connection and use NHS information services such as the National electronic Library for Health
- Agreed pilots for electronic prescribing.
- By March 2002:
- 100% of general practices to be computerised
- 100% of general practices to have an NHSnet connection with email and web browsing
- Desktop connection for NHS clinical staff to basic email, browsing and directory services
- 60% of all haematology, biochemistry and microbiology test results to be transmitted electronically.
- By March 2003:
- All radiology reports and discharge summaries to be transmitted electronically between hospital and GPs
- Start to change from Read Codes to SNOMED Clinical Terms
- All practices to have disease registers in place.
- April 2004:
- Electronic prescribing to be available.
- By 2005:
- A vibrant, networked NHS
- All bookings from GPs to outpatients to be electronic
- Electronic transfer of records in primary care
- All trusts to have level three electronic patient records
- The first generation of electronic health records
- All local health services to have telemedicine, allowing patients to connect electronically with staff for advice.
An electronic patient record describes the concept of a longitudinal record of periodic care provided mainly by one institution. This will typically relate to the healthcare provided by an acute hospital. Table 1 (below) details the proposed levels within an electronic patient record.
Table 1: Proposed levels of electronic patient records
|Level 6||Advanced multimedia and telematics
As level 5, plus telemedicine, other multimedia applications (e.g. picture archiving and communications systems)
|Level 5||Specialty specific support
As level 4, plus special clinical modules, document imaging
|Level 4||Clinical knowledge and decision support
As level 3, plus electronic access to knowledge bases, embedded guidelines, rules, electronic alerts, expert support systems
|Level 3||Clinical activity support
As level 2, plus electronic clinical orders, results, reporting, prescribing, multiprofessional pathways
|Level 2||Integrated clinical diagnosis and treatment support
As level 1, plus integrated master index, departmental systems
|Level 1||Clinical administrative data
Patient administration and independent department systems
The electronic health record is used to describe the concept of a longitudinal record of a patient's health and healthcare from cradle to grave (see Figure 1, below). It combines information about the patient's contacts with primary healthcare with subsets of information associated with the outcomes of periodic care in the electronic patient record.
|Figure 1: The complete electronic patient record|
An electronic patient record would contain information that must only be made available to specified people. It is therefore important for an electronic patient record to have different levels of access for NHS staff.
The Government wants to be seen to be putting patients first. By providing patients with health information online via NHS Direct Online, and offering a round-the-clock free health advice line via NHS Direct, the Government believes that this is being achieved.
The cost of providing this service both in terms of personnel and the IT infrastructure is enormous.
A prescription is currently printed in the surgery, given to the patient and then taken to a pharmacy. The pharmacy enters all the information printed on the prescription into its computer.
The prescription is then sent to the Prescription Pricing Authority (PPA) and the details entered on their computer. This information is then used to produce Prescribing and Analyses and Cost (PACT) data and to pay the pharmacy or the practice.
A method by which data can be transmitted electronically from the practice to the pharmacy, and then from the pharmacy to the PPA, has considerable advantages. There will be savings in terms of duplication of data entry, the risk of data error will be Yignificantly reduced, and dispensing fees should be paid within days instead of months.
Trials are due to start shortly to establish the most cost-effective method of electronic prescribing. It is envisaged that, in 2004, electronic prescribing will be a reality. The programme of establishing this in all practices and pharmacies will then commence.
Electronic appointment booking
By March 2005, practices are expected to be booking all outpatient appointments electronically. This will reduce the 'did not attend' rate by involving the patient in the choice of appointment time and date. The hospital will save considerable time by not having to book and send out appointments.
There is no gain to the practice and they will have to invest in staff to enable the electronic booking of appointments. General practice therefore needs to ensure that resources are transferred to enable this process.
National electronic Library for Health
See Guidelines in Practice February 2001; 4(2) for an explanation of the structure of the National electronic Library for Health, highlighting the benefits for primary care professionals and patients.
None of these developments will be of benefit to patients if NHS staff are not trained. Training is not one of the great strengths of the NHS. Resources need to be made available to ensure that all staff are trained in order to gain maximum benefit from all future IT developments.
A modern practice IT system, with networked computers available to all staff, a connection to NHSnet and a clinical system, can cost between £40 000 and £80 000.
It is no longer acceptable to expect practices to make this sort of investment and only receive 50% reimbursement. Continual investment will be required to replace or upgrade equipment as well as to maintain the existing infrastructure.
NHSnet is a model that must be followed. The General Practitioners Committee of the BMA negotiated for all hardware, installation, connection and calls associated with NHSnet to be free for all practices. The only area not covered by this agreement was ongoing maintenance.
All the above developments need to be funded in a similar way, as does the maintenance of equipment.
Until recently, the use of computers in general practice has been optional, although 99% of practices currently have a computer. With more data being recorded and transmitted electronically, the electronic record will soon be established as the primary record and replace the Lloyd George envelope.
- NHS Executive. Information for Health: An information strategy for the modern NHS 1998–2005. London: NHSE, 1998. Also available at: www.nhsia.nhs.uk/
- NHS Executive. Building the Information Core – Implementing the NHS Plan. London: NHSE, January 2001. Also available at: www.doh.gov.uk/nhsexipu/strategy/overview