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Information Technology in the English National Health Service

Information Technology in the English National Health Service In 2002, the British government announced the largest sustained spending growth in the history of the National Health Service (NHS), with total UK health spending increasing from 7.7% of gross domestic product to 9.4% over 5 years (from 2002-2003 to 2007-2008).1 A key driver for this massive increase in expenditure was the need to make more effective use of information technology (IT), the costs of which were estimated to increase to 4% of the total budget. Over 10 years, this would amount to an investment of approximately £18 billion (US $32 billion) for all NHS IT expenditure, a subcomponent of which is the investment in the national program. This program is intended to connect 36 000 general practitioners (primary care physicians) in more than 8000 practices and 270 acute hospitals, community, or mental health organizations in England with a national information system.2 It does not cover Scotland, Northern Ireland, or Wales. Much of this investment will be undertaken locally in hospitals and in physicians' offices in the community. The national program is managed by a central organization, NHS Connecting for Health,3 and its size and complexity make it currently the largest in the world and the most extensive civilian IT investment in the United Kingdom.4 Design The core of the program is a new national network to provide a rapid, reliable, and secure broadband network to transfer clinical data between all NHS organizations. A key feature is that, as the volume of traffic increases, the quality of each individual connection does not degrade. A national data “spine” holds demographic information about every citizen in England (approximately 50 million people). This includes the name, date of birth and address, the general practitioner with whom the person is registered, and the unique NHS number allocated to every person at birth. The NHS number was developed in the mid-1990s to enable both the anonymization of medical records and the possibility of linking records held in different locations to improve the quality of care and research. If the person does not object, the personal spine information service will also contain a summary of clinical conditions and major treatments. This information will support the secondary users service that will provide anonymous data for public health and health services research. A protected Web service called “health space” will eventually provide patients with access to the summary part of their NHS Care Record Service (NHS CRS) held on the personal spine information service. An individual will be able to note information concerning his or her health, health needs, care plans, or particular wishes in relation to clinical interventions, and to access this using a home computer. The spine also supports the transmission of information between the other components of the system. These include the booking facility (Choose and Book), the picture archiving and communications system, the quality management and audit system, which is the basis of the remuneration system for general practitioners, the electronic prescription service, the national directory of all NHS staff and organizations, and links with local service providers (LSPs). Systems and services to the local NHS providers are being developed and delivered through 5 LSPs, who each cover a different region serving populations that range from 7.2 million in London to 13 million in the south of England. The LSPs are responsible for procuring or developing a range of systems to support patient administration in hospitals, including the electronic clinical records, general practice records, electronic prescribing, pharmacy, ambulance, and other systems to enable better integration across health communities. Other systems under development include clinical decision support, emergency care, mental health patient administration, and clinical care pathway support systems. Procurement An output-based specification was made available to interested bidders in mid-2003 and published on the Internet. This was developed with input from clinicians and described, in full, what the successful suppliers were required to build. Contestability was achieved by awarding contracts to multiple suppliers to ensure a managed competitive environment to create a pressure on price and an incentive for quality and productivity. To maximize the competitive advantage of the NHS, negotiations continued with 2 or 3 short-listed bidders in parallel until contracts were awarded. Contracts can be terminated without compensation for work already completed in the event of significant failure. One of the innovations of the new procurement regime is enterprise-wide arrangements with common subcontractors. This arrangement ensures that the NHS obtains prices for hardware, software, and services commensurate with the size and purchasing power of the NHS. This means that the rates the NHS pay must be the lowest available, anywhere in the world. The total savings predicted are approximately £860 million (US $1.5 billion) through these arrangements. These savings are in addition to those achieved, during the procurements, of in excess of £4.6 billion (US $8.2 billion).4 Progress The National Audit Office in the United Kingdom scrutinizes public spending on behalf of Parliament. Its recent report, which includes a full description of the program, concluded that substantial progress had been made but significant challenges remain.4 The new national network has been installed with more than 15 000 connections, including 98% of general practices.5 This provides a national e-mail and directory service for all NHS staff. In August 2006, there were 197 000 registered users sending 328 248 e-mails a day. A picture archiving and communications system has been developed to capture, store, and distribute static or moving digital images, such as radiographs and scans. Currently, 1 picture archiving and communications system is going live every week and more than 56 million images are stored. The program's original plan to enable patient referrals between different practitioners was extended, by means of the new Choose and Book system, to facilitate patient choice as well as the electronic booking of first hospital outpatient appointments by general practitioners. This program failed to meet its target of universal electronic booking by the end of 2005, but its performance has improved now with 62% of general practitioners using the service and 10 000 patients benefiting daily. Another key part of the program is the electronic prescription service, which enables general practitioners to prescribe medication electronically and to transmit prescriptions to pharmacists.6 Currently, coverage is at 17% of general practitioner practices and 16% of pharmacies, with 47 000 prescriptions being handled daily. In a typical month, NHS Connecting for Health stores 8.5 million images, transmits 1.5 million patient-related messages, sends 1.8 million pathology test results, 14 million e-mails, 600 000 letters to patients, and transmits 100 terabytes of data over the new national network, equivalent to 4.5 billion written pages.4 The quality management and audit system was delivered on time to the 8298 general practices by March 2006. Costs The main contracts for the National and the LSP systems, at a cost of £6.2 billion (US $11.2 billion), were negotiated in 2003 and 2004 on a fixed price and are being managed within this total.4 The estimated total cost of the program is now £12.4 billion (US $22.3 billion) at 2004-2005 prices over the 10-year life of the main contracts. This includes the cost of extra features added to the scope since 2002, as well as central administration and local implementation costs.4 The government maintains that the total IT cost in the NHS over the 10-year period up to 2013 will be approximately £20 billion (US $36 billion). The NHS CRS The NHS CRS is the foundation of the program and, perhaps not surprisingly, its development has proved to be difficult and controversial.2,7 The NHS CRS consists of 1 summary record to be held on the spine and 1 or more detailed care records held locally. Deployment of the summary record was planned in pilot form from late 2004 but is now expected early next year, 2 years behind schedule. Questions concerning the content of these records, integration, security, and accessibility have arisen and not yet been entirely resolved.2,4,7 It is intended that the summary care record will contain all significant aspects of a person's care, such as major diagnoses and problems, procedures, current and regular prescriptions, allergies, adverse reactions, drug interactions, recent investigation results, hospital discharge summaries, outpatient summaries, and summaries from pathways of care. The summary care record will be derived from the detailed patient record systems of all organizations providing care to the individual. The intent is for every person in the country to receive next year a leaflet describing the system and its current state of development. It is currently held that individuals do not have the right by law to dictate in what form the NHS keeps information about them, whether it is demographic or clinical information. They also do not have the right by law to object to demographic information being shared to provide them with care. They do, however, have the right to object to clinical information being shared, provided withholding this information does not pose a risk to others in the population. Individuals will be able to indicate to a clinician at any time their wish to restrict sharing their clinical information. This will include the summary care record created from the detailed care record held by their general practitioner. For those individuals who do not object, information initially will be uploaded from general practices that have reached certain quality standards and that are using SNOMED (Systematized Nomenclature of Medicine) codes.8 Patients will be informed by letter when this process is about to begin in their practice. When they next visit the practice, there will be an opportunity to review the content of the summary record, make changes, and agree what further information should be placed within it. With regard to the detailed care record, patients can ask that certain information should not be recorded in their record; however, clinicians do have a duty to keep proper records and therefore some negotiation may be necessary. Particularly sensitive information may be held in a sealed envelope within the electronic record, which can only be accessed with the explicit permission of the patient. Detailed Care Records More than 90% of general practices in England are computerized, with patients' medical records being held electronically in at least a third (Gillian Braunold, MRCGP, written communication, October 11, 2006). Detailed care records are also held by other health care practitioners in the community and in hospitals. Records developed by an LSP within an area supported by a single server (termed instances in IT jargon) can be integrated to enable a single, immediately updatable record to be available irrespective of the location in which the patient is treated. Again rules governing sharing will need to be approved by the patient. The potential exists to improve the care of patients with chronic illnesses—records to support care pathways are being developed; for example, for individuals with diabetes mellitus. Initially such integrated systems will be available locally, within an instance (single server), although the use of the summary record held on the spine should enable better coordination and sharing of clinical information outside the local area. A particular problem is that hospitals have lagged behind general practice in developing electronic medical records.2 At Great Ormond Street Hospital, which is the largest children's hospital in the United Kingdom, it is planned over the next 3 years to introduce an electronic medical record, although there are still technical problems to be resolved. This will include connectivity with the NHS CRS and the capacity to share information, as appropriate and with consent, with caregivers outside of the NHS, including social and education services. In a hospital with a large number of specialties, the systems architecture for the foreseeable future must be heterogeneous, even if it is built around a small number of core applications. Projects include updating patient management systems, introducing spine-based identity and authentication management (legitimate access), and an electronic prescribing and medicines administration system. Two key principles should exist for this system to work. The first key principle is that the NHS CRS, even if it does not form the whole of the applications environment, will form the central core and should not, from the user's perspective, be differentiated from local systems. The second key principle is the importance of system usability. These 2 principles are not only compatible but also mutually reinforcing. Taking usability first, it is a lesson hard learned that the best-quality clinical information (defined in terms of accuracy, richness, and timeliness) requires input by clinicians at the point of care. This obviously requires well-designed clinical applications, but also that all of a wide range of usability issues are solved. For example, are there enough system access devices? Are they in the right places (or capable of being easily moved to the right place)? Do legitimate access and security issues hinder access to systems and discourage their use? Is the proliferation of applications only adding to the confusion as to where information can be found? Another strategic goal is to simplify and improve processes through the reduction and, where cost-effective, eventual elimination of paper as a medium of information transmission and storage. Wireless technology has already gone a long way to improve device accessibility. “Thin client” technology, by moving data processing away from desktop computers to powerful central servers, will allow the full value of investment in legacy systems to be realized, and an evolutionary approach to the development of the clinical systems environment to be taken. Access and security systems will be linked to the NHS smart card, which allied to single sign-on will provide the universal means of access to all systems. Access and Confidentiality As the national program has developed, major concerns regarding confidentiality and accessibility have been raised and indeed are still matters of controversy. Only health care professionals with a legitimate reason for accessing a patient's notes will be able to do so. An audit trail will be established on each and every occasion that a patient's medical records are accessed. Each health care professional will carry a smart card with identity assurance systems before he or she can access records, and the card will carry digital information concerning the extent and type of access to which that person is entitled. While no individual has the right to opt out of the demographic record, he or she can opt out of all aspects of the summary care record and can request that all detailed care records held by clinicians or health care centers be held nondigitally in paper format or in nonconnected electronic systems (Table). A Care Record Guarantee, a guarantee from the NHS to each citizen, has been issued9 and will be updated every 6 months as experience accumulates. The main issue at present concerns the secondary use of information. As currently planned, it will be possible for each citizen to indicate whether he or she wishes information from their summary care record to be transferred, for example, to disease or illness-based registries, or to be made available to the pharmaceutical industry. Such information can be made available after anonymization without the individual's specific permission, although each person will have the right to object to his or her information being anonymized in the first instance. Further work, not least from experience, will be required to understand how this system can best be developed, but indications from public surveys suggest that most people are content to allow their information to be used as long as they are asked and it is for a purpose that is of benefit to society or to themselves.10 Debate continues regarding the use of patient-identifiable information without individual consent, in certain specific circumstances relating to the public good.11 Table. Medical Records—Questions and Answers for Patients Table. Medical Records—Questions and Answers for Patients View LargeDownload Conclusions Good progress has been made in designing and procuring a comprehensive IT service to support the NHS in England. Much remains to be done. Many of the new hardware and software systems are not yet in place but should become available over the next 3 years, although there are still technical problems to be resolved. Perhaps the greatest challenge to successful implementation to improve the quality and efficiency of health care is the human processes that need to change to accommodate the IT revolution. Otherwise, manual processes will simply be replaced with digital ones. More precision about the definition and use of terms will be required.12 The National Audit Office report emphasized the need to win the support of staff and to determine the changes necessary in the way the service is managed and care is delivered.4 Above all will be the need to provide sufficient training for staff, especially clinicians, to use the new systems. Back to top Article Information Corresponding Author: Cyril Chantler, MD, King's Fund, 11-13 Cavendish Square, London W1G 0AN, England (chantler@doctors.org.uk). Financial Disclosures: Dr Chantler was chairman of the Shared Record development committee for NHS Connecting for Health and is chairman of the King's Fund and chairman of Great Ormond Street Hospital. Mr Clarke is director of Clinical Services and deputy chief executive of Great Ormond Street Hospital. Mr Granger is director general of NHS Information Technology and senior responsible owner of the program. Acknowledgment: We thank colleagues in NHS Connecting for Health, particularly Marlene Winfield, BA, Gillian Braunold, MRCGP, Christopher Exeter, PhD, and David Bowen, MSc, at Great Ormond Street Hospital for their assistance. No compensation was given for their assistance. References 1. HM Treasury. Government spending review of 2002: chapter 7. http://www.hm-treasury.gov.uk/spending_review/spend_sr02/spend_sr02_index.cfm. Accessed August 17, 2006 2. Cross M. Will Connecting for Health deliver its promises? BMJ. 2006;332:599-60116528086Google ScholarCrossref 3. NHS Connecting for Health. NHS National Programme for Information Technology. http://www.connectingforhealth.nhs.uk. Accessed August 29, 2006 4. National Audit Office. The National Programme for IT in the NHS. http://www.nao.org.uk. Accessed August 17, 2006 5. Chief Executive's Report to the NHS: December 2005. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/AnnualReports/fs/en. Accessed August 29, 2006 6. NHS Connecting for Health. NHS Connecting for Health Fact Sheet. http://www.connectingforhealth.nhs.uk/publications/nhs_cfh_factsheet.pdf. Accessed August 29, 2006 7. Cross M. Keeping the NHS electronic spine on track BMJ. 2006;332:656-65816543338Google ScholarCrossref 8. NHS Connecting for Health. Standards proposal announced by NHS Connecting for Health and SNOMED. http://www.connectingforhealth.nhs.uk/news/snomed011105. Accessed August 29, 2006 9. NHS Connecting for Health. Care Record Development Board. NHS Care Record Guarantee. http://www.connectingforhealth.nhs.uk/crdb/. Accessed August 29, 2006 10. NHS Connecting for Health. NHS Information Authority. Share With Care. http://www.connectingforhealth.nhs.uk/publications/share_with_care.pdf. Accessed August 21, 2006 11. Souhami R. Governance of research that uses identifiable personal data. BMJ. 2006;333:315-31616902204Google ScholarCrossref 12. NHS Connecting for Health. Standards launch by Information Standards Board. http://www.connectingforhealth.nhs.uk/news/isb_feature. Accessed August 28, 2006 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Information Technology in the English National Health Service

JAMA , Volume 296 (18) – Nov 8, 2006

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References (7)

Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.296.18.2255
Publisher site
See Article on Publisher Site

Abstract

In 2002, the British government announced the largest sustained spending growth in the history of the National Health Service (NHS), with total UK health spending increasing from 7.7% of gross domestic product to 9.4% over 5 years (from 2002-2003 to 2007-2008).1 A key driver for this massive increase in expenditure was the need to make more effective use of information technology (IT), the costs of which were estimated to increase to 4% of the total budget. Over 10 years, this would amount to an investment of approximately £18 billion (US $32 billion) for all NHS IT expenditure, a subcomponent of which is the investment in the national program. This program is intended to connect 36 000 general practitioners (primary care physicians) in more than 8000 practices and 270 acute hospitals, community, or mental health organizations in England with a national information system.2 It does not cover Scotland, Northern Ireland, or Wales. Much of this investment will be undertaken locally in hospitals and in physicians' offices in the community. The national program is managed by a central organization, NHS Connecting for Health,3 and its size and complexity make it currently the largest in the world and the most extensive civilian IT investment in the United Kingdom.4 Design The core of the program is a new national network to provide a rapid, reliable, and secure broadband network to transfer clinical data between all NHS organizations. A key feature is that, as the volume of traffic increases, the quality of each individual connection does not degrade. A national data “spine” holds demographic information about every citizen in England (approximately 50 million people). This includes the name, date of birth and address, the general practitioner with whom the person is registered, and the unique NHS number allocated to every person at birth. The NHS number was developed in the mid-1990s to enable both the anonymization of medical records and the possibility of linking records held in different locations to improve the quality of care and research. If the person does not object, the personal spine information service will also contain a summary of clinical conditions and major treatments. This information will support the secondary users service that will provide anonymous data for public health and health services research. A protected Web service called “health space” will eventually provide patients with access to the summary part of their NHS Care Record Service (NHS CRS) held on the personal spine information service. An individual will be able to note information concerning his or her health, health needs, care plans, or particular wishes in relation to clinical interventions, and to access this using a home computer. The spine also supports the transmission of information between the other components of the system. These include the booking facility (Choose and Book), the picture archiving and communications system, the quality management and audit system, which is the basis of the remuneration system for general practitioners, the electronic prescription service, the national directory of all NHS staff and organizations, and links with local service providers (LSPs). Systems and services to the local NHS providers are being developed and delivered through 5 LSPs, who each cover a different region serving populations that range from 7.2 million in London to 13 million in the south of England. The LSPs are responsible for procuring or developing a range of systems to support patient administration in hospitals, including the electronic clinical records, general practice records, electronic prescribing, pharmacy, ambulance, and other systems to enable better integration across health communities. Other systems under development include clinical decision support, emergency care, mental health patient administration, and clinical care pathway support systems. Procurement An output-based specification was made available to interested bidders in mid-2003 and published on the Internet. This was developed with input from clinicians and described, in full, what the successful suppliers were required to build. Contestability was achieved by awarding contracts to multiple suppliers to ensure a managed competitive environment to create a pressure on price and an incentive for quality and productivity. To maximize the competitive advantage of the NHS, negotiations continued with 2 or 3 short-listed bidders in parallel until contracts were awarded. Contracts can be terminated without compensation for work already completed in the event of significant failure. One of the innovations of the new procurement regime is enterprise-wide arrangements with common subcontractors. This arrangement ensures that the NHS obtains prices for hardware, software, and services commensurate with the size and purchasing power of the NHS. This means that the rates the NHS pay must be the lowest available, anywhere in the world. The total savings predicted are approximately £860 million (US $1.5 billion) through these arrangements. These savings are in addition to those achieved, during the procurements, of in excess of £4.6 billion (US $8.2 billion).4 Progress The National Audit Office in the United Kingdom scrutinizes public spending on behalf of Parliament. Its recent report, which includes a full description of the program, concluded that substantial progress had been made but significant challenges remain.4 The new national network has been installed with more than 15 000 connections, including 98% of general practices.5 This provides a national e-mail and directory service for all NHS staff. In August 2006, there were 197 000 registered users sending 328 248 e-mails a day. A picture archiving and communications system has been developed to capture, store, and distribute static or moving digital images, such as radiographs and scans. Currently, 1 picture archiving and communications system is going live every week and more than 56 million images are stored. The program's original plan to enable patient referrals between different practitioners was extended, by means of the new Choose and Book system, to facilitate patient choice as well as the electronic booking of first hospital outpatient appointments by general practitioners. This program failed to meet its target of universal electronic booking by the end of 2005, but its performance has improved now with 62% of general practitioners using the service and 10 000 patients benefiting daily. Another key part of the program is the electronic prescription service, which enables general practitioners to prescribe medication electronically and to transmit prescriptions to pharmacists.6 Currently, coverage is at 17% of general practitioner practices and 16% of pharmacies, with 47 000 prescriptions being handled daily. In a typical month, NHS Connecting for Health stores 8.5 million images, transmits 1.5 million patient-related messages, sends 1.8 million pathology test results, 14 million e-mails, 600 000 letters to patients, and transmits 100 terabytes of data over the new national network, equivalent to 4.5 billion written pages.4 The quality management and audit system was delivered on time to the 8298 general practices by March 2006. Costs The main contracts for the National and the LSP systems, at a cost of £6.2 billion (US $11.2 billion), were negotiated in 2003 and 2004 on a fixed price and are being managed within this total.4 The estimated total cost of the program is now £12.4 billion (US $22.3 billion) at 2004-2005 prices over the 10-year life of the main contracts. This includes the cost of extra features added to the scope since 2002, as well as central administration and local implementation costs.4 The government maintains that the total IT cost in the NHS over the 10-year period up to 2013 will be approximately £20 billion (US $36 billion). The NHS CRS The NHS CRS is the foundation of the program and, perhaps not surprisingly, its development has proved to be difficult and controversial.2,7 The NHS CRS consists of 1 summary record to be held on the spine and 1 or more detailed care records held locally. Deployment of the summary record was planned in pilot form from late 2004 but is now expected early next year, 2 years behind schedule. Questions concerning the content of these records, integration, security, and accessibility have arisen and not yet been entirely resolved.2,4,7 It is intended that the summary care record will contain all significant aspects of a person's care, such as major diagnoses and problems, procedures, current and regular prescriptions, allergies, adverse reactions, drug interactions, recent investigation results, hospital discharge summaries, outpatient summaries, and summaries from pathways of care. The summary care record will be derived from the detailed patient record systems of all organizations providing care to the individual. The intent is for every person in the country to receive next year a leaflet describing the system and its current state of development. It is currently held that individuals do not have the right by law to dictate in what form the NHS keeps information about them, whether it is demographic or clinical information. They also do not have the right by law to object to demographic information being shared to provide them with care. They do, however, have the right to object to clinical information being shared, provided withholding this information does not pose a risk to others in the population. Individuals will be able to indicate to a clinician at any time their wish to restrict sharing their clinical information. This will include the summary care record created from the detailed care record held by their general practitioner. For those individuals who do not object, information initially will be uploaded from general practices that have reached certain quality standards and that are using SNOMED (Systematized Nomenclature of Medicine) codes.8 Patients will be informed by letter when this process is about to begin in their practice. When they next visit the practice, there will be an opportunity to review the content of the summary record, make changes, and agree what further information should be placed within it. With regard to the detailed care record, patients can ask that certain information should not be recorded in their record; however, clinicians do have a duty to keep proper records and therefore some negotiation may be necessary. Particularly sensitive information may be held in a sealed envelope within the electronic record, which can only be accessed with the explicit permission of the patient. Detailed Care Records More than 90% of general practices in England are computerized, with patients' medical records being held electronically in at least a third (Gillian Braunold, MRCGP, written communication, October 11, 2006). Detailed care records are also held by other health care practitioners in the community and in hospitals. Records developed by an LSP within an area supported by a single server (termed instances in IT jargon) can be integrated to enable a single, immediately updatable record to be available irrespective of the location in which the patient is treated. Again rules governing sharing will need to be approved by the patient. The potential exists to improve the care of patients with chronic illnesses—records to support care pathways are being developed; for example, for individuals with diabetes mellitus. Initially such integrated systems will be available locally, within an instance (single server), although the use of the summary record held on the spine should enable better coordination and sharing of clinical information outside the local area. A particular problem is that hospitals have lagged behind general practice in developing electronic medical records.2 At Great Ormond Street Hospital, which is the largest children's hospital in the United Kingdom, it is planned over the next 3 years to introduce an electronic medical record, although there are still technical problems to be resolved. This will include connectivity with the NHS CRS and the capacity to share information, as appropriate and with consent, with caregivers outside of the NHS, including social and education services. In a hospital with a large number of specialties, the systems architecture for the foreseeable future must be heterogeneous, even if it is built around a small number of core applications. Projects include updating patient management systems, introducing spine-based identity and authentication management (legitimate access), and an electronic prescribing and medicines administration system. Two key principles should exist for this system to work. The first key principle is that the NHS CRS, even if it does not form the whole of the applications environment, will form the central core and should not, from the user's perspective, be differentiated from local systems. The second key principle is the importance of system usability. These 2 principles are not only compatible but also mutually reinforcing. Taking usability first, it is a lesson hard learned that the best-quality clinical information (defined in terms of accuracy, richness, and timeliness) requires input by clinicians at the point of care. This obviously requires well-designed clinical applications, but also that all of a wide range of usability issues are solved. For example, are there enough system access devices? Are they in the right places (or capable of being easily moved to the right place)? Do legitimate access and security issues hinder access to systems and discourage their use? Is the proliferation of applications only adding to the confusion as to where information can be found? Another strategic goal is to simplify and improve processes through the reduction and, where cost-effective, eventual elimination of paper as a medium of information transmission and storage. Wireless technology has already gone a long way to improve device accessibility. “Thin client” technology, by moving data processing away from desktop computers to powerful central servers, will allow the full value of investment in legacy systems to be realized, and an evolutionary approach to the development of the clinical systems environment to be taken. Access and security systems will be linked to the NHS smart card, which allied to single sign-on will provide the universal means of access to all systems. Access and Confidentiality As the national program has developed, major concerns regarding confidentiality and accessibility have been raised and indeed are still matters of controversy. Only health care professionals with a legitimate reason for accessing a patient's notes will be able to do so. An audit trail will be established on each and every occasion that a patient's medical records are accessed. Each health care professional will carry a smart card with identity assurance systems before he or she can access records, and the card will carry digital information concerning the extent and type of access to which that person is entitled. While no individual has the right to opt out of the demographic record, he or she can opt out of all aspects of the summary care record and can request that all detailed care records held by clinicians or health care centers be held nondigitally in paper format or in nonconnected electronic systems (Table). A Care Record Guarantee, a guarantee from the NHS to each citizen, has been issued9 and will be updated every 6 months as experience accumulates. The main issue at present concerns the secondary use of information. As currently planned, it will be possible for each citizen to indicate whether he or she wishes information from their summary care record to be transferred, for example, to disease or illness-based registries, or to be made available to the pharmaceutical industry. Such information can be made available after anonymization without the individual's specific permission, although each person will have the right to object to his or her information being anonymized in the first instance. Further work, not least from experience, will be required to understand how this system can best be developed, but indications from public surveys suggest that most people are content to allow their information to be used as long as they are asked and it is for a purpose that is of benefit to society or to themselves.10 Debate continues regarding the use of patient-identifiable information without individual consent, in certain specific circumstances relating to the public good.11 Table. Medical Records—Questions and Answers for Patients Table. Medical Records—Questions and Answers for Patients View LargeDownload Conclusions Good progress has been made in designing and procuring a comprehensive IT service to support the NHS in England. Much remains to be done. Many of the new hardware and software systems are not yet in place but should become available over the next 3 years, although there are still technical problems to be resolved. Perhaps the greatest challenge to successful implementation to improve the quality and efficiency of health care is the human processes that need to change to accommodate the IT revolution. Otherwise, manual processes will simply be replaced with digital ones. More precision about the definition and use of terms will be required.12 The National Audit Office report emphasized the need to win the support of staff and to determine the changes necessary in the way the service is managed and care is delivered.4 Above all will be the need to provide sufficient training for staff, especially clinicians, to use the new systems. Back to top Article Information Corresponding Author: Cyril Chantler, MD, King's Fund, 11-13 Cavendish Square, London W1G 0AN, England (chantler@doctors.org.uk). Financial Disclosures: Dr Chantler was chairman of the Shared Record development committee for NHS Connecting for Health and is chairman of the King's Fund and chairman of Great Ormond Street Hospital. Mr Clarke is director of Clinical Services and deputy chief executive of Great Ormond Street Hospital. Mr Granger is director general of NHS Information Technology and senior responsible owner of the program. Acknowledgment: We thank colleagues in NHS Connecting for Health, particularly Marlene Winfield, BA, Gillian Braunold, MRCGP, Christopher Exeter, PhD, and David Bowen, MSc, at Great Ormond Street Hospital for their assistance. No compensation was given for their assistance. References 1. HM Treasury. Government spending review of 2002: chapter 7. http://www.hm-treasury.gov.uk/spending_review/spend_sr02/spend_sr02_index.cfm. Accessed August 17, 2006 2. Cross M. Will Connecting for Health deliver its promises? BMJ. 2006;332:599-60116528086Google ScholarCrossref 3. NHS Connecting for Health. NHS National Programme for Information Technology. http://www.connectingforhealth.nhs.uk. Accessed August 29, 2006 4. National Audit Office. The National Programme for IT in the NHS. http://www.nao.org.uk. Accessed August 17, 2006 5. Chief Executive's Report to the NHS: December 2005. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/AnnualReports/fs/en. Accessed August 29, 2006 6. NHS Connecting for Health. NHS Connecting for Health Fact Sheet. http://www.connectingforhealth.nhs.uk/publications/nhs_cfh_factsheet.pdf. Accessed August 29, 2006 7. Cross M. Keeping the NHS electronic spine on track BMJ. 2006;332:656-65816543338Google ScholarCrossref 8. NHS Connecting for Health. Standards proposal announced by NHS Connecting for Health and SNOMED. http://www.connectingforhealth.nhs.uk/news/snomed011105. Accessed August 29, 2006 9. NHS Connecting for Health. Care Record Development Board. NHS Care Record Guarantee. http://www.connectingforhealth.nhs.uk/crdb/. Accessed August 29, 2006 10. NHS Connecting for Health. NHS Information Authority. Share With Care. http://www.connectingforhealth.nhs.uk/publications/share_with_care.pdf. Accessed August 21, 2006 11. Souhami R. Governance of research that uses identifiable personal data. BMJ. 2006;333:315-31616902204Google ScholarCrossref 12. NHS Connecting for Health. Standards launch by Information Standards Board. http://www.connectingforhealth.nhs.uk/news/isb_feature. Accessed August 28, 2006

Journal

JAMAAmerican Medical Association

Published: Nov 8, 2006

Keywords: information sciences,communication and information technology

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