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NHS IT: an uncertain prognosis for electronic records

Posted by admin on Tue, 07/09/2010 - 13:02
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The first comprehensive study of the implementation of NHS electronic healthcare records in England has found delays and frustration with the system and uncertainty over the political impact of the new government. 

The study, conducted by researchers from The University of Edinburgh, The London School of Economics and Political Science, The School of Pharmacy and The University of Nottingham, assessed the development and rollout of the NHS Care Records Service in the National Programme for IT (NPfIT).
 
The research team assessed the implementation of electronic records in five NHS acute hospital and mental health trusts from across the National Programme for IT regions in England. Their evaluation consisted of interviews with NHS trust staff, observations and reviewing key documents.
 
A major factor impacting on the findings was the high degree of uncertainty surrounding the future of the Programme as a whole given the advent of the new Coalition Government and the commitment to cutbacks in the public sector. 
 
The researchers note: “Despite recognised successes in delivering components of the overall programme - for instance, introducing a fast NHS broadband network (N3) and picture archiving and communications systems in all hospitals—the National Programme for IT has struggled to deliver the NHS Care Records Service as originally envisioned in the planned timescale. Consequently, it has attracted negative media coverage and critical questioning by parliamentary bodies charged with scrutinising government spending.
 
“Both NHS trust interviewees and local service providers expressed fears that progress in developing the central NHS IT infrastructure and shared detailed electronic health records could be lost, with a considerable waste of public money and effort already expended,” they added.
 
“The future of the National Programme for IT is still uncertain in light of the new coalition government taking office and forthcoming cuts in public spending. Some fear that policy makers might now swing from the initial top-down approach to the opposite, a bottom-up approach, whereas the more desirable approach suggested by several interviewees is a hybrid of the two, recognising a place for both central and local responsibilities and with efforts at sharing detailed electronic health records focused on local health communities.”
 
Still support
 
But the researchers found there was still strong support for the basic principle of electronic patient records, but a high degree of frustration with the current implementation of them.  One problem that was identified was the 'top down' approach to centrally negotiated contracts and the “ruthless standardisation” model adopted by the Department of Health (DoH).  With the new government seemingly more inclined towards a 'bottom up' approach to procurement, respondents voiced concerns that individual trusts would have to shoulder responsibility for sourcing IT and that this in turn might lead to challenges with interoperability. 
 
“Although a few interviewees perceived benefits in the local choice and sense of ownership that a bottom-up approach would bring, others believed it currently impossible to integrate disparate systems and that attempting to do so would set back electronic health records by many years,” note the research team, adding: “Any detailed electronic health record resulting from a 'bottom-up' approach would not be a single, shared electronic health record.”
 
But respondents also dislike having to work with centrally negotiated contracts. Trusts wanted standard solutions tailored to individual NHS trusts that could be quickly responsive to changing central and local NHS priorities.“The “customers” for the NHS Care Records Service—the hospital trusts—have no direct contractual relation with NHS Connecting for Health, the local service providers, or the suppliers of the NHS Care Records Service applications,” observes the research group. “The difficulties arising from this arrangement were evident from NHS interviewees repeatedly speaking of convoluted communication channels and, particularly, frustratingly slow response times to deal with requests for software fixes or changes.”
 
The future?
 
After surveying the study's conclusions, the research team has produced a number of policy related recommendations. 
  • The DoH should acknowledge inconsistencies between, on the one hand, promoting NHS internal markets and foundations trusts and, on the other, the inflexibility of long term, centrally negotiated contracts that exclude the NHS trust “customer.” 
  • There needs to be greater consistency and clearer information about the future of the National Programme for IT  to help alleviate some current uncertainties. 
  • NHS trusts need to be allowed to communicate changing local and national NHS priorities directly to those working with them to implement electronic health records. 
  • Abandon the principle of paying  local service provider payments on delivery and tie contract payments to more thoughtfully agreed outcomes instead. 
  • Open up the future direction of NpfIT to wider public discussion and debate over aspects such as what kind of detailed electronic health record is wanted, on what scale, and how much the country is prepared to pay for it.
The research report concludes: “Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. 
 
“Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations’ perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.”