Originally Published MX March/April 2005
IT IN HEALTHCARE
Toward a National IT Infrastructure for HealthcareThe UK's National Health Service is leading what is dubbed the world's largest IT program for healthcare.
Ian Howells
Where technology is concerned, healthcare professionals in the United Kingdom have often turned to their colleagues across the Atlantic for inspiration. But while U.S.-based institutions have pioneered the application of information technology (IT) to many areas of healthcare, the UK is now firmly ahead in terms of making progress toward establishing a national IT infrastructure for healthcare. The U.S. secretary of health and human services and President Bush have been visiting U.S. medical centers to discuss nationwide healthcare reform and see firsthand how IT can play a major role in that transformation. The UK, however, is already in action. Indeed, the $11-billion National Programme for Information Technology (NPfIT) currently being implemented by the National Health Service (NHS) is said to be the world's largest healthcare IT initiative to date.
The origins of the NPfIT lie in the "Information for Health" strategy published by NHS in 1998.1 Two years later, the launch of the UK government's 10-year plan for NHS underlined the importance of a strategy of this nature.
The NHS plan emphasized that the health service should be designed around the needs of the patient, offering more flexibility in when and where the patient could gain access to treatment. It was recognized from the outset that these needs could not be successfully met without a national IT infrastructure in place. As the 2002 Wanless Report stated: "Without a major advance in the effective use of information and communications technology, the health service will find it increasingly difficult to deliver the efficient, high-quality service which the public will demand. This is a major priority, which will have a crucial impact on the health service over future years."2
The NPfIT, launched in October 2002, is seen as the key to realizing the NHS plan. As such, it will help to resolve some of the issues that have plagued NHS as a result of its perceived focus on bureaucracy and organizational structures rather than patients. Among these issues are the following:
- Data relating to a single patient are held by disparate systems in various locations, with no method of uniting the data to create a whole view of that patient.
- Healthcare professionals lack the information they need to deliver efficient, high-quality service.
- Patients cannot access information and care services directly.
- Patients who are referred for specialist consultations or treatments often face lengthy waiting times.
To be fair, many of the difficulties facing NHS are shared by public- and private-sector organizations the world over. NHS is not unique in having an inadequate, piecemeal IT infrastructure that consists of many isolated systems with a large amount of data overlap and duplication. Each system typically stores and manages its own data, which cannot easily be exchanged with other systems. Moreover, many processes carried out within NHS—including scanning and imaging—are still based largely or entirely on paper or film, and are therefore laborious and time-consuming.
A Common Platform
The NPfIT is a very ambitious program, involving the investment of $11 billion between 2003 and 2010. It aims to create a new digital infrastructure that will enable all NHS stakeholders in England to communicate on a common platform. It will incorporate existing systems where compatible.
Implementation of the NPfIT will mark a shift from systems organized along institutional lines—each of them dealing with a small fraction of patient interactions—to a more holistic approach. As a result, patients will be provided more quickly with more-accurate diagnosis and care, and will become increasingly involved in the decision-making process. Healthcare professionals will benefit from a reduction in administrative costs coupled with improved information access. NHS itself expects to realize massive savings in time and costs.
At the core of the NPfIT is the creation of single-patient electronic records that can be accessed around the clock by every authorized healthcare professional in the NHS and by patients themselves. This NHS Care Records Service (CRS) will support the care of more than 50 million English patients in every situation and every location. It will also form the basis for electronic care pathways, a mechanism for flagging those patients who are considered to be at high risk or who have a particular medical condition.
Another core NPfIT deliverable is an electronic booking service, which is known as Choose and Book. This groundbreaking development enables general practitioners (GPs) and other primary-care staff to book appointments on-line while the patient is present. "Patients will be able to choose an appointment convenient for them, so that it fits in around their family or work commitments," said UK Health Secretary John Reid. "This is an excellent example of how technology will transform the experience of patients."3
Further, a program to enable the electronic transfer of prescriptions (ETP) will allow prescriptions to be created electronically by a GP and then transferred directly to the pharmacist, as well as to the country's prescription pricing authority. Information about the prescription will be incorporated into the patient's care record. Against a background of 6% annual growth in the number of prescriptions issued in the UK, ETP will save a great deal of time and effort for all parties involved, while also reducing errors.
To help deliver these and other services, the NPfIT has contracted British Telecommunications plc (London) to set up a new network called N3. N3 will use broadband connections to introduce new channels such as videoconferencing and to enable the exchange of x-ray images, scans, video sequences, and other large data files. In fact, the nationwide introduction of a picture archiving and communications system (PACS) technology is a core NPfIT deliverable in its own right. The intention is for PACS to become a communitywide image-management system across all NHS sites.
Challenges for the Program
Rollout of the NPfIT will not come without some challenges and potential pitfalls, of course. Although the program's individual elements are all proven in practice, they have never before been implemented on such a scale. In addition, past performance of the UK public sector with respect to large IT projects causes the risks to be perceived as high. Close attention has therefore been paid to the creation of robust, clearly defined supplier relationships. Also, steps have been taken to ensure that funding is not diverted elsewhere. Implementation follows a carefully designed, phased approach.
One of the major challenges the program faces is to blend the old and new successfully. Integration is an important objective but not an easy one to achieve, given the number and diversity of systems in existence. The use of sophisticated integration platforms that offer both connectivity with the widest possible range of systems and platforms and the functionality to direct and manage information flows therefore is essential. NHS has also decreed that all new implementations must comply with NPfIT standards for interoperability.
Security, another key challenge, is the subject of an overall strategy that imposes rigorous technical requirements on all NPfIT suppliers. NHS is placing emphasis on information governance, data quality, and auditing, as well as on making sure that all systems are well protected against security breaches and failures. In addition, specific elements of the program have their own security features, which are often very sophisticated.
A certain amount of resistance to the NPfIT is inevitable. Some will come from those who have "always done it this way" and some from critics who see IT as a drain on scarce resources. To counter this resistance, NHS has engaged in a major publicity drive. A Web site (www.npfit.nhs.uk) is one of its cornerstones. Clinicians, whose involvement and commitment are regarded as crucial, are being targeted in a variety of ways. Some, for example, have joined group fact-finding visits to technologically innovative institutions in the United States.
CRS Taking Shape
The initial phases of the NPfIT have focused primarily on CRS, which is being implemented using a two-tiered approach involving a national application service provider (NASP) and five local service providers (LSPs). The NASP, British Telecommunications, is responsible for providing a national data spine, so called, of uniquely identified summary patient records. The LSPs are charged with implementing more-detailed CRS elements. A specifically designed access control service will manage registration and authentication of users, who must first establish a legitimate relationship with the patient. Authorized users have access only to the information that pertains to their role, and parts of a record may be unavailable for routine sharing. Patients will be able to view their own records.
Not surprisingly, the number of organizations involved in the NPfIT is extremely large. Consultancies, hardware manufacturers, and both software and service providers are participating. As far as CRS is concerned, the key players are those such as iSoft plc (Manchester, UK) and IDX Systems UK Ltd. (London), that supply applications for viewing and managing patient records, and those responsible for the all-important, though less immediately obvious, integration element.
SeeBeyond (Bracknell, Berkshire, UK) provides the core integration software for CRS at the national level. The integration and business process management capabilities of the company's integrated composite application network (ICAN) suite will form the foundation of the transactional messaging service that processes and routes data to and from a wide variety of systems that are all linked to the national spine. In addition, SeeBeyond supplies the recording and cross-indexing capabilities needed to create unique single-patient records.
At a local level, SeeBeyond provides the integration platform for three LSPs: British Telecommunications, Computer Sciences Corp. UK (Aldershot, Hampshire, UK), and Fujitsu Services Ltd. (Feltham, Middlesex, UK). Its technology enables these providers to communicate with the NHS national data spine and with numerous legacy applications currently in use within the NHS trusts in their service regions.
From Planning to Implementation
Several elements of CRS have already been delivered. Basic patient records are expected to come on-line in mid-2005, along with the ability of GPs to transfer data directly among themselves. Over time, the scope of CRS will expand to include diagnostic images, pathology results, and decision-support tools.
Progress has also been made on the other key CRS elements. Under the management of Atos Origin UK (London) as NASP, the Choose and Book service was launched in the summer of 2004 at a small number of pilot sites and later extended. The technical design work on ETP is already complete; that prescription-transfer program is about to be launched, with full deployment expected by 2007. By March 2005, there should be 6000 connections to the new N3 network.
Other important developments include the rollout of CRS-compatible PACS technology, which began last summer and is expected to achieve complete national coverage by 2007. The UK's PACS will make it possible for clinicians to access, transmit, and store images electronically—rather than printing hard copies to be filed manually—enabling doctors to provide faster diagnosis and saving hospitals the costs involved in purchasing, processing, and storing film.
Medical devices such as scanning and x-ray equipment will be integrated into CRS so that health professionals across NHS will be able to access a patient's digital images with the touch of a button. Early PACS implementers are already reporting enormous benefits, not all of which were anticipated at the outset. Says Will Smith, superintendent radiographer at Princess Royal Hospital near Shrewsbury in Shropshire: "One helpful by-product of the introduction of PACS is that the number of internal phone calls has fallen by 90%. Previously, all these calls were from doctors and clinicians trying to track down a patient's x-rays within the hospital."4
Other benefits include better service to patients, faster diagnosis, and reduction of patient wait times. Minimizing the risk of film loss and eliminating the need to wait for film to be developed are also viewed as key benefits.
Conclusion
This has been by no means an exhaustive account of this immense project. For example, no mention has been made of procurement or of training, both of which are accorded a high priority. Nevertheless, it is clear that the UK health service's NPfIT has gathered considerable momentum and is well on the way to achieving its objectives. The program is an extremely exciting project not only because of its scale but also because it will inevitably affect the way patient information is managed in the future worldwide. The NPfIT is an example for all countries that are looking to implement an integrated national healthcare IT system.
References
Ian Howells, PhD, is vice president for worldwide marketing at SeeBeyond (Bracknell, Berkshire, UK), which provides a suite of software for advanced integration and business process management.
Copyright ©2005 MX
