CfH technology boss says paper not fit for purpose

07 Jul 2008

Connecting for Health’s chief technology officer, Paul Jones has stressed the importance of integrating standards to achieve interoperability in healthcare, saying paper is “no longer fit for purpose”.

Speaking at last week's Connecting for Health’s SNOMED CT and interoperable healthcare conference, Jones said health providers were under increased pressure to ensure the care they provide is “safe, effective, reproducible and state-of-the-art”.

“It should also be available wherever a patient is and able to deal with whatever is wrong with them, aiding prevention of any further illnesses or harm,” he added.

Jones said CfH aimed to achieve connected healthcare through the use of common standards allowing all healthcare systems to interoperate.

“Paper is no longer fit for purpose. It introduces multiple themes – safety and completeness, care plans and pathways, workload and availability and so on…Everyone has their own idea of good, but there is no need to worry because we have standards – and lots of them,” Jones said.

These include terminologies such as Read and SNOMED CT, classifications such as OPCS, the NHS data dictionary, messaging standards including HL7, and different content modelling standards.

“They all have a role to play in the context of electronic health records, including recording, decision making, searching, categorising data and being interoperable with other systems used across healthcare settings,” he said.

Jones quoted Sir John Harvey-Jones, former chairman of Imperial Chemical Industries, saying: “Planning is an unnatural process; it is much more fun to do something. And the nicest thing about not planning is that failure comes as a complete surprise rather than being preceded by a period of worry and depression.”

Looking to the future, he spoke about CfH’s involvement in the Open Health Tools initiative - a collaborative effort between international health agencies, major healthcare providers and international standards organisations.

The collaboration are looking to create a new type of interoperable standard, which will be known as the Logical Record Architecture.

This will work closely with the OHT Platform, consisting of a Health Service Bus providing common services, such as reporting, analytics, data interchange, security, and medical device integration, and the Service Library providing terminology services, public health services such as outbreak management and extensibility technologies like web services.

The Health Service Bus will integrate with all point of service applications, as well as data access applications, enabling standardised interoperable service delivery.

The Logical Record Architecture will ensure that all healthcare systems meet clinical governance, information governance and regulatory requirements from conception to implementation.

Jones concluded: “Remember, it is all about sharing.”

Reader's Comments

In support of paper (etc)

07 Jul 08 08:05

1. Paper has stoof the test of time. Nothing CfH has yet delivered comes anywhere near it in terms of reliability and expressivity.

2. There is not yet the technology to efficiently capture detailed (as opposed to summary) electronic records across the board using available medical terminologies.

3. I don't recall ICI ever having planned to do the impossible.

4. IMHO it's mainly about clinicians looking after individual patients in their care; it's certainly not ALL about sharing (though if CfH seriously believes this, then that explains a lot!)

Another techie with no clinical background....

07 Jul 08 10:38

Listening to the speech last Wednesday, I was once again struck by the blind and stupid belief that technology is the answer to everything....not 42. There was no mention of patient confidentiality, no mention of security as a priority, no mention of the failures to provide true clinical functionality.....nothing.

The speech reminded me of the story about how NASA spent a fortune on an anti-gravity pen, while the Russians used a pencil. The slide used to illustrate the hand-over from the paramedics highlighted a simple lesson to me. A latex glove can convey more information to a clinician treating an unwell 67 year old male, than any system provided by CfH after hundreds of millions of pounds.

CfH looks like it's no further forward in its thinking despite all the lessons learned. Maybe it is. It just doesn't look like it.

"It's all about sharing"...OK then....share with us the true cost and contractual frameworks that are sucking the enthusiasm of every health professional who believes in IT as a mechanism to deliver better patient care! There are health professionals who want this to succeed but they are slowly moving towards extinction. And with speeches like that last Wednesday, I can see why!

I've read the Magna Carta

07 Jul 08 11:13

I've read the Magna Carta; some problems with the latin, but still readable despite being written in 1215 AD

However my then expensive 3M CD-R discs I bought in 1998 and burnt at 2x are not, the music is unplayable. Lost. However the original Vinyl LPs still play! Ye Gods!

How long before the electronic data is zapped by misuse, people with tacky fingers or a neutron pulse from outer-space?

So on the whole -paper wins out on the longevity front. (although the Magna Carta was written on vellum -to stop smartie comments - you get my point?)

Bills Says...

07 Jul 08 11:32

"Sometimes the best emulation of a piece of paper is just a piece of paper."

IT as an enabler in NHS - Not Yet

Adrian.Kearns@westmidlands.nhs.uk

07 Jul 08 11:41

Informationa Technology Systems should be an enabler in a process and the development, design and deployment should be mindfull of this.

PAPER CURRENTLY ENABLES and has delivered on time without systemic failures and less than expected results.

Inherently I believe in the value of CfH as an Enterprise Resource Planning tool but I begin to have concerns that more and more its fixing process and operational flow in Healthcare that is not in the best interests of the end user and the patient.

Paper is fantastic tool but I know that there are many pro-technology clinicians out there who are content in using middleware or transitional applications either built in-house and bespoked or purchased of the shelf but until there is consistent delivery of user friendly clinical support systems with rapid access and stability od operation the Clinician about to operate, prescribe or make a diagnosis will still trust the ream of paer in his hands constituing the Complete HealthCare Record.

Another 5 years of non-delivery?

07 Jul 08 11:51

I was also at the meeting. Specification of tangible artifacts which are to emerge from the Logical Record Achitecture project were conspicuously absent.

To my jaundiced eyes, this is merely the latest concoction of the tiny cadre of CfH 'experts' and contractors at the heart of the NPfIT project looking to justify their continued employment.

Meanwhile the CfH obsession with coding everything which moves continues. A document management system could deliver >95% of the sharing of individual patient records needed for clinical care with comparitive ease. Coding always disregards potentially human readable information - even when everyone codes to the same standards and questions from the floor about these were deftly sidestepped by the panel.

If we cannot get it right on paper

07 Jul 08 13:06

If we cannot get records right on paper, we have no chance with computerising the records! Using paper and brains and thinking can produce invaluable clinical records. Using computers and little thought can produce gigabytes of rubbish, which inevitable someone then prints out and sends to me as an all embracing referral! The language of medicine is so economical and effective, brief and free text - most database designers refuse to allow free text. A good GP can make a tremendously informative referral in well under 300 words of free text.

I have found repeatedly that unless we can make our processes work on paper, computerising is a disaster.

In Support of 'If you cant get it right on paper..'

07 Jul 08 16:45

In his speech to the CfH SNOMED CT and Interoperable Healthcare event last week, Dr Mark Davies (National Clinical Director for CfH) quoted some interesting statistics about coding systems which is worth pondering. I hope Dr Davies doesnt mind me repeating his information on these pages for the benefit of EHI readers.

According to Dr Davies SNOMED CT has 400,000 terms where ICD10 and OPCS have a mere 15,000 and 5000 respectively. Dr Davies went on to point out that the English language has about 600,000 words. Does this not point out a major weakness in SNOMED? You might as well write the blooming thing down in English mate! At least we can all understand that. At what point does a coding system become a language in its own right?

OK I’m making a rather crass point at SNOMED's expense put there is a serious point hidden in my rather flip observation. The obsession with coding everything completely ignores the propensity for coders to code the wrong thing or code the same thing as different things. The more complex a coding system becomes, the more it is at the mercy of ‘interpretation’ or worse error. Anyone involved with the mere 15,000 ICDS10 codes will know what difficulty this causes. At the moment these errors (and there are plenty) only have an effect in cash terms. When doctors start making decisions based on them then the game gets very serious indeed.

So back to paper and what has the above got to do with all that. Well its this. A picture speaks a thousand words. And you cant do that with a computer screen yet. So stop trying. A very wise person said to me once, a paperless office is as likely as a paperless toilet.

hollow rhetoric for HIT by CfH

cpoee1@yahoo.com

08 Jul 08 05:07

There has been galloping exuberance for HIT by those who do not have to use it to manage a complex illness involving multiple systems with disease. The reports that HIT is safe and effective is hollow rhetoric influenced by the for profit motives of the HIT manufacturers and their paid booth bunnies who have duped the NHS leaders...a trojan horse. HIT has never been scientifically proven to be safe and efficacious, nor has it been scientifically proven to assure the "state-of-the art", whatever that is. When did CTO Paul Jones last use a paper chart for the care of a patient?

Cepi

re: hollow rhetoric for HIT by CfH

08 Jul 08 12:31

Nuts!

Regardless of CfH, you only have to look at GP Practices to see that this point of view does not make sense.

Forgetting the financial incentives for collecting QOF information, I doubt you will find a single GP Practice in the country who would agree to dump their Existing IT system and go back to paper only.

The main reason for this is that GPs have recognised the fact that their IT system (whatever flavour) gives them the ability to PROACTIVELY manage patient conditions i.e. clinical evidence shows that a patient with x and y is likely to develop z. Being able to run an automated report in seconds* which shows all practice patients with x and y allows those patients to be contacted directly for tests to see if they are developing z - you simply cannot do this easily on paper.

In addition most clinicians don’t tend to carry the whole of the BNF in their head. The ability to see possible interactions and side effects automatically at the point of prescribing should not be underestimated in terms of patient safety.

Most practices are paperless now and cannot operate for more than a day without their IT system, although I say paperless somewhat tongue in cheek, as although they are paperless internally, they need to generate rainforests worth of paper to communicate with anyone externally.

Please stop generalising Heath IT as being "bad" just because of the problems experienced to date by CfH.

* Torex products not included :)

Sometimes the technology makes paper the only safe way!

09 Jul 08 09:14

OK so electronic is the future but lets get the current versions to work first. data standards do not fix everything and both user & data provider perspectives need to be put into the design of every combination of systems. In the absence of perfection a paper based backup may be the only safe way of transferring data as format and content is under the control of the sender.

Curent pathology result messaging has several problems and that standard has been in use for years by a large number of laboratories and GP practices :-

1) There is a capability to give free text comments from the laboratory to the doctor - Laboratories use it for reference ranges which cannot be handled otherwise (eg LMP dependent ones for reproductive hormones), advice on further testing, help with interpretation of results, some test results and messages about errors which make results incorrect (There is no result retraction process so how else can we do it?). When the message is received some GP systems hide this text - The GP seems to be expected to know there is a message in order to go and find it.

2) If an NHS number is present in the message at least one GP system automatically matches the incomming messages on the basis of this data item regardless of other patient demographics which do not match. Sounds like it shouldnt happen but the wrong NHS number, date of birth etc can get on pathology systems very easily given a hand written request form and the current absence of any method of confirming in real time that a previously unknown NHS number actually belongs to the named individual. Even something as trivial as your driving licence number is more securely linked to you.

3) If there is no automatic merge to the database, practice staff are apparently free to merge incomming messages manually to any patient in the GP database and there seems to be no monitoring of the degree of data match. We have individual examples where matching was minimal, for example only gender & date of birth corresponded. There seem to be no GP system tools which can give an overall perspective about the frequency & degree of this issue.

That mess is just my list of the known problems with one fundamental data link delivered between our laboratory and 70 GP practices. The standard was drafted and applied but that does not mean differing system suppliers apply it in the same way and it can take years to find out there is a problem with a particular combination.

It's not what you do, it's what you use it for..

preston.demendonca@nhs.net

09 Jul 08 10:19

Steve Jobs to Seymour Cray : "We are using a Cray 2 to design our next generation of Apple computers" Seymour Cray to Steve Jobs : "That's interesting,I'm using an Apple to design my next Cray supercomputer."

Welcome the cynics and confound the Luddites

09 Jul 08 21:48

Having delivered computer systems in a variety of industries over the last 30 years, I can only say that I have found the technology-cynics to be far more helpful than the IT-geeks, as they always tell you where it may go wrong - giving you a fighting chance of getting it right if you listen. However, the sheer ease of paper is part of the problem - it is too easy for Luddites to sit back and not face up to the very real challenges facing the practice of medicine - as has been pointed out in commment #10; we can't just keep on doing it the 'old way'. Patients and younger clinicians simply cannot believe that so much is still being done in such a crude fashion while they are busily using the new technologies. It was way back in 1996 that the Audit Commission found that 35% of hospital records were lost or missing (a critical downside of paper) - OK, this is EHI Primary Care - things are different in GP land, of course. Frankly, the IT is not really the key issue - it should just be a tool to help you do things better (usually differently too) and faster (once you get through the teething problems - how long does it take to get a trainee or junior doctor to take a good patient notes that help others deliver reliable care?). Keep being cynical, but, above all, try leading from the front rather than sniping from behind, though that is much easier to do too.

The old really don't understand e-records

10 Jul 08 20:52

The NHS MUST make appropriate provision for the ageing population it serves

Not only my own generation (nearing 60, I can still remember my old alphanumeric NHS number - I believe the same as my birth certificate, from my son's - but haven't a clue as to my 'new', valid numeric number) but my parents' generation grew up knowing only paper records, so they must be able to access information in a way that is acceptable to them, not to "the powers that be" (sic)

My 86 year old mother recently received a letter from her bank claiming that they had no record to check her signature against (she has had an account for probably at least 40 years - an experience similar to a recently-retired member of staff, whose bank refused to implement a transfer of funds to another bank as they "had no record whatsoever of her signature") so she must visit a bank branch (as a nursing home resident this is impossible) and take her driving licence (she has never had one) or passport (this expired 5 years ago, so the signature is 15 years old)

What a load of XXXX! Not even NI numbers are unique to one individual (see today's press for a tragic story with resultant destitution), and the CRB will brand innocent individuals with the criminal record of someone who previously bore the same name (see yesterday's press), so do we have a hope in XXXX of implementing a reliable EHR?

I fear not, especially as the data within it may not be truly comparable even if it all really originates from the same person . . .