OOH Report Message Requirement Application
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The submission is being made by;
Dr Paul Cundy Manager MSW ERDIP NHS Direct and GP OH links Project MD GePmail Ltd (declared interest) The Surgery 35A High Street Wimbledon SW19 5BY cunpr@globalnet.co.uk 0208 946 6559
Local support from
John Sidman LIS Programme Director Sutton and Merton PCT The Wilson Cranmer Road Mitcham Surrey CR4 4TP 020 8687 4779
Suggested Name
The suggested name of the standard is;
Out of Hours report message
The standard was developed by the MSW NHS Direct and GP OOH links ERDIP Project (www.nhsia.nhs.uk/def/pages/pr/29012002_2.asp). The message is based on a theoretical message specification developed by Dr David Markwell under contract to the Northumberland Health Action Zone’s GP Connect project. Two iterations of modifications were made to this message as a result of practical experience gained from operational implementation in the MSW ERDIP and other sites. The Northumberland HAZ scheme has now closed. Modifications to the message continue in the light of increasing usage and extending source system interfacing. The MSW NHS Direct and GP OOH links ERDIP project is also now closed but contact details are as for Dr Paul Cundy above.
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Purpose and Scope of the standard
The purpose of the standard is primarily to deliver the service needs detailed in the requirements section, secure two way EDI clinical and administrative communications for GP Out of hours (GP OOH) services. There are also a range of secondary purposes that can be identified. Primary purpose To enable EDI links between GP OOH services and clinical systems within general practices. Enabling call records and reports of consultations to be transferred direct to practices. This will help to ensure continuity of care and support the development of “life long” primary care records. “GP OOH Links” is analogous to Registration and Item of Service links. This electronically links GP Co-operatives and deputising services with GP surgeries so that call records can be transferred direct to the practice’s clinical computer system. This occurs over NHS net using securely encrypted messages and is EDI at both sender and recipient sites with no need for any re-keying of data. It utilises existing data captured from existing clinical activity, there is no extra workload or data collection for the GP OOH clinical or administrative staff. It also enables GP surgeries to submit electronic feedback or “Blue” forms and to alert their GP OOH service to patients with special needs. Therefore clinical feedback to the patients registered GP will be possible wherever the patient is in the country and wherever and however they make contact with the GP OOH service. The principal functionalities are; 1. GP OOH reports and contact details entered into GP computer records without re-keying or faxing A record of a patient's contact with a GP OOH service is delivered electronically to that patient's GP's surgery and thereafter inserted automatically, without any re-keying of data, into that patient's electronic clinical record. This is desktop to desktop communication between GP OOH doctors and the patient's GP. “Our OOH and NHS D links are valuable resource, when patients present, especially when they’ve been prescribed medication OOH, we’ve got it on the screen already” Linda Hicks, Practice manager, Drs Christie, Kandasamy & Quinton, Southfields, London.
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2. Feeding back to GP OOH services Having received a note of the contact between his patient and the GP OOH service, the patient's registered GP, or one of his colleague's or a member of his staff, can use the system to send feedback up to the OOH service using the electronic equivalent of the NHS Direct blue form. GP OOH service staff and clinicians can find out what happened to the patients they advised or treated. 3. Advising GP OOH services about patients with special needs Used by the practice to alert GP OOH services about patients with special needs, such as the terminally ill, mentally ill or addicts. These three functionalities are delivered by the message being submitted for draft standard approval. These functionalities are also delivered by this message for NHS Direct but this is subject of a separate application because of the different policy backgrounds. The functionalities below are delivered by other messages within the system. 4. Security and confidentiality for clinical messaging All communications in this system are protected using PKI encryption and digital signatures. 5. Practice opening times, doctor’s availability and On Call Instructions Enables the practice to populate their GP OOH service databases, again securely automatically and seamlessly with no re-keying of data, with schedules of their opening hours and out of hours duty doctor contact details covering the entire 24 hour period. The GP OOH service will thus always know when, where and how to contact the practice's duty doctor Secondary purposes 1. Workload Currently where GP OOH services communicate with general practices activity is faxed to practices where it is then re-keyed into the GPs computer. By eliminating re-keying of data both at the call centre and at the practice this system abolishes Out of Hours paper workloads. “If I think back 10 years to the hours it used to take doing this manually with faxes and paper dockets from the OOH service, now its all done (electronically) in a matter of minutes”. Nick Shimmin, Practice manager, Drs Sharma, Ewen & Bobak, 13-15 Barmouth Road, Wandsworth, London. 2. Safety Using electronic data interchange between the various practice and GP OOH databases the system abolishes transcription and other human errors caused when data is otherwise faxed or telephoned through. Transcription errors are abolished.
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This is an area of critical importance for deputising services in their maintenance of surgery cover hours. 3. Modular, meeting the various needs of general practices the system is modular, fitting into virtually any practice IT and workflow configuration. All the practice needs is a connection to the NHS net. Interfacing with GP clinical systems (In Practice Systems and TOREX) is via system supplier derived API toolsets, a new development in the GP system supplier market. 4. Standards The system is consistent with the concept of standards, having collaborated with Dr David Markwell and Mr Andrew Perry, consultants to the Northumberland Health Action Zone Connect project. The core clinical messages are based on the ENV13606 message. 5. Quality and monitoring of OOH services The system is capable of delivering a wide range of performance and quality indicators by local reporting and analysis of the content of the delivered messages. The message carries all the timings and duration data logged by the host GP OOH service, see the management report on the ERDIP web site; (www.nhsia.nhs.uk/erdip/archive/documents/mert/deliverables/mert4-2.doc).
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Justification of the requirement
The requirement is justified by in a wide range of evidence on both business need and support and at all levels of the NHS. General Service level. Within the NHS the GP is the current guardian of the lifelong record and until distributed electronic health records are firmly established the GP surgery will continue to collect and collate the patients lifelong healthcare record prior to dispatch to the patients next General Practice. GP OOH services – the “Co-op movement” Since changes in 1994 to the GP contract, the creation of the Out of Hours Development Fund and the expansion of GP Co-operatives a clear need to provide clinical communications between the GP’s Out of hours service and the subscribing practice was established. More recently plans to integrate NHS Direct, GP Co-ops and Deputising services into a unified OOH service clearly re-state this need. The new GP contract The new GP contract will allow practices to opt out of OOH care completely but still provide care for their patients during daytime office hours. This re-enforces the need for clinical feedback. The need to provide for continuity of care is in itself self evident and will become ever more important as the delivery of care in a modernised NHS becomes ever more disparate. General Practice In addition to the quotes from users elsewhere in this application the following give an indication as to the requirement recognised by primary care staff; “its useful timely information, its there at a press of a button, its very easy to search on, its an extremely useful way of receiving, collecting and collating information”. Sheila Mclean, Laindon Health Centre, Laindon, Essex, SS15 5TR. “One word; brilliant” Jenny Ridge, Practice Manager, Mayfield Surgery, 246 Roehampton Lane, London, SW15 4AA “its very useful, saves a lot of time, yes its very very good” Kathy Ring, Practice Manager, Parchmore medical Centre, Parchmore Road, Thornton Heath, CL7 8LY “It’s a good idea, its certainly gonna save time” Ann Compton, The Surgery, Eastwick Park Road, Bookham, KT23 3ND
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GP System User Groups GP System users have also identified the need (Torus, The Journal of the Torex User Group, December 2000). Professional level Continuity of care and clinical feedback underpin quality health care; GMC The GMC states in its “Good Medical Practice for General Practitioners” a requirement for effective clinical feedback and handover. In the context GP OOH care this can only be achieved if out-of-hours providers supply to GPs, by 9.00 a.m. on the next normal working day full records of patient contacts. Similarly GPs need to be able to notify GP OOH services about patients with special needs. Informatics The requirement for these communications was formally identified by the Joint Computing Group of the RCGP and the GPC in 1999 (Statement of general practitioner user requirements for networking connections in support of clinical and administrative practice in primary care (version 2.0), Joint Computing Group of the RCGP and the GPC, November 1999) Subsequently the Joint Computing Group of the RCGP and the GPC considered the system that is the subject of this application and recommended that the project apply to have the message incorporated into RFA (Minutes of Joint Computing Group of the RCGP and the GPC 14 th December 2000, GPC 65 2000-2001, agenda item 9).
NHS Management requirements RFA/NAPPS In response to the JCG recommendation the RFA team were preparing an IGN to specify a requirement for GP systems suppliers to interface to the message via an “Out of Practice message” but this was not published because of the transition to NAPPS. Integrating Emergency Care Last year Dr David Carsens reported to the Government on the needs of integrated emergency care in “Raising standards for patients New partnerships in Out of Hours care” (www.doh.gov.uk/pricare/oohreport.htm). This report stated several relevant requirements. “Report Recommendation Four: When the Electronic Health Record is in place, a three-way exchange of data between NHS Direct, out-of-hours providers and GP clinical systems should be established. In the interim, all providers should report all out-of-hours consultations to GPs by 9.00 a.m. the next normal working day. Systems for the
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three-way sharing of clinical data for patients with special needs should be established in advance of the implementation of the Electronic Patient Record”. This requirement is being delivered by implementations of this message.
Subsequently the DOH published its guidance in “The Roles and Responsibilities of Those Engaged in the Delivery of GP Out-of-Hours Services, Notes for GPs, PCTs and Organised Providers in Respect of Reporting and Accreditation, June 2002” (http://www.doh.gov.uk/pricare/oohroles.pdf). A clear need for this message is derived from Quality Standard 8 which states; “Quality Standard 8: Out-of-hours providers must be able to supply full clinical details of all consultations to the host GP by the start of the next working day and providers will monitor the flow of information within and between provider organisations. This message is the only mechanism that can currently achieve this quality DOH quality requirement and satisfy professional concerns of security and confidentiality. This quality requirement is supposed to commence from October 1 st 2002.
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Strategy External review of NHS policy Professor Denis Protti in his report for the NHSIA titled “IMPLEMENTING INFORMATION FOR HEALTH: EVEN MORE CHALLENGING THAN EXPECTED?” published in June 2002 wrote; “It cannot be anything but encouraging to hear of the ERDIP site that successfully completed the enhancement of systems at GP practices and NHS Direct to permit the generation of a message, its automatic transfer, and receipt. The messages successfully transferred were:
From NHS Direct to practices: A call record detailing the content and outcome of a call to NHS Direct From Practices to NHSD: “Blue forms” and alert to NHS Direct of patients with special needs. Appointment availability messages are next. Even without them, the pilot project to create two-way, PKI secured, electronic links between NHSD and GPs desktops over NHS net has to be deemed a success. Excitement should be mounting in anticipation of the same functionality being made available across the country”. The functionality he describes is identical for the GP OOH environment.
NHSIA programs of work Earlier this year the NHSIA clinical communications board commissioned a study on the requirements for clinical communications in the NHS. A program of work has been identified (www.nhsia.nhs.uk/clinicalcomms/pages/default.asp). This identifies the need for OOH to GP messaging and NHS Direct to GP messaging. Both requirements are being met by the use of this message but to technical and strategic specifications that exceed the expectations of the report (www.nhsia.nhs.uk/clinicalcomms/pages/docs/strategy.pdf) ICRS The DOH paper “Delivering 21st Century IT, Support for the NHS National Specification for Integrated Care Records Service published in July 2002 (www.doh.gov.uk/ipu/whatnew/specs_12d.htm) specifically refers in the section detailing services to be delivered nationally within the NHS to the development of this message (page 171, section 10.5.4).
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NHS Direct The DOH in its publication; “NHS Direct a new gateway to healthcare”, 2001, states a requirement for electronic communications between NHS Direct sites and GP surgeries; “By 2004,.......electronic links between NHS Direct, out-of-hours providers and the patients registered GP will ensure that details of a patients consultation with NHS Direct are available to the health professional handling the next stage of their care”. This message delivers this functionality in full. Government At the projects demonstration day on February 1 st 2002 Mr Andrew Pinder, the Governments e-Envoy called for the system to be implemented nationally when he made the following statement to a large invited audience at BMA house; “It (the system) fills a real need and a need which at some point needs to be rolled out nationally. This is an important building block and we greatly welcome it……………... The other 16 (ERDIP Projects) are also doing innovative things but this one is a real gem and it is one which we look forward to seeing being increasingly developed into the future.” Since February the team has continued to develop the standard and the system and we believe it is now ready to be adopted as an NHS Standard.
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Successful continuing implementations in typical NHS settings;
There are currently a total of 72 sites with the system installed; 4 different GP OOH organizations consisting of 3 deputising services (Healthcall, MSW GP Nightline and National Nightline) and 2 GP Co-ops (Thamesdoc and Croydoc), 1 NHS Direct site (South London) and 68 GP surgeries (addresses can be supplied if required) representing, approximately 380 GPs. Some of these sites have been operational with predecessor systems since 1996. 43 practices are using the message to receive reports only from their GP OOH services (i.e. OOH to GP messaging). 26 Practices are using the message to receive reports from both their GP OOH service and NHS Direct (i.e. OOH to GP messaging and NHS Direct to GP messaging). Approximately 2% of the countries population is covered by the system over a geographical area stretching from Essex to Portsmouth. Balham Tooting and Wandsworth PCG has installed a total of 21 sites to enable secure NHS Direct and OOH links as well as secure communications between GP surgeries and GP surgeries and the PCG. Thamesdoc, a large GP Co-operative based in the south east is installing the system in all of its 120 subscribing practices in support of its groundbreaking integrated emergency care scheme launched on August 1 st. New installations are currently occurring at 5-10 per week in the South East as GP OOH organizations and PCTs providing it for their GPs. Principle contact details of operational implementations are as below but full contact details for all the sites can be provided if required. MSW GP Nightline deputising service Mrs Linda Hill 0208 947 4556 Balham Tooting and Wandsworth PCG Mr Majid Saber 0208 874 8134 Thamesdoc GP Co-op Mr Stephen Price 0208 390 9991 Croydoc GP Co-op Dr Agnelo Fernandez 0181 251 4200
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Nestor PLC (deputising service) David Randall 01908 691919
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Detail the benefits / dis-benefits of the standard.
The system has been independently audited and shown to save practices staff time, no longer having to deal with multiple faxes. For the average practice it takes 5 minutes to download a weekends messages and insert them into the electronic patient records. Practice managers can run monthly reports to reconcile against Co-op invoices. Patient’s contacts with OOH services can be recalled or searched for in seconds. Amongst our existing users there is a 100% renewal rate. The software system was evaluated by Dr Paul Steventon in 1998 on behalf of the MSW GP Nightline board. He concluded the system was appropriately priced and that it was a sensible development for a GP OOH service. GP OOH services that utilize the system are able to offer subscribers that use it differential charges. In south London Healthcall offer a discount to subscribing practices that use the system of £10 per GP per month and £1 off each and every patient contact or consultation. These costs savings are derived from their no longer having to pay staff to handle practice on call instructions rotas (which are now uploaded system to system) and that the call duration of an electronically delivered report as compared to a faxed consultation report is the order of 10 x shorter. For the average GP this saving would amount to £260 per year in addition to his own staff time savings. There are also additional savings from the fact that once transmitted the practice can generate their own duplicate reports locally whereas failed faxes need to be re-transmitted from the OOH centre. There are of course less tangible but equally important benefits in terms of guaranteed clinical feedback and continuity of care. The only known dis-benefit reported to us by users of the system is information excess. “The downside (of the system) is the quality of information, there’s nothing wrong with the links system, that’s absolutley fine, it’s the quality of the content and information from the OOH service that could be better”. Linda Hicks, Practice manager, Drs Christie, Kandasamy & Quinton, Southfields, London. When viewed on the screen this can mean that several pages need to be scrolled through to get to the final outcome. When posted to the GP clinical system large amounts of negative and non contributory data is being inserted into the patients HR. In order to deal with this the system has been modified so that whilst the practice always receives the entire report they can decide which components of the report are posted into the GP clinical system. This is set up via a configuration dialog screen in the system. Practices can select or deselect any or any combination of the messages structured elements. In addition a library of style sheets is being developed that the practice can choose from to display the reports. A summary style sheet will only display the information most likely to be of interest to a clinician.
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Risks and alternatives
There are no known current alternative international OOH links standard messages. The only other OOH messaging system known to the team is a proprietary product between EMIS and Adastra systems. This is thought to be a “digitised fax” system using e-mail. These are sent as uncoded and unstructured plain text with no privacy enhancing technologies (PETs) and are either re-keyed by the practice or are appended to the HR in the same way as a scanned document i.e. as non codified data. The only risks we can foresee of approving this standard are the fact that the message is an ENV message and that it is not HL7v3. However a clear migration pathway exists and it is the intention of the project team to undertake this work in the near future. Approval is thus being sought on the basis that this is an operational working message and that it will migrate to HL7v3 when appropriate. There is however we feel a far greater and more likely risk of not approving this standard. The need for OOH to GP communications is self evident and now expected to be a national level quality standard as from October. Unless the NHS gives a clear signal as to the future direction and if possible offers a working solution a multitude of locally specified and procured GP OOH links systems based on local proprietary communications solutions might spring up, in exactly the same way that local NHS net connectivity solutions sprang up in the late 1990s.
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Costs and funding arrangements
The cost to a practice of the software system that handles the message is £500 annually. This includes installation, on site and on line support, all updates. Support from users of the system is evident in that the renewal rate is 100% and the client base is expanding rapidly. GP system suppliers There have been no identified costs to GP system suppliers since 1996. In Practice Systems and Torex have this year made available to the applicant their system APIs. IPS is currently migrating its client base of 600+ practices to Vision version 3 and this version is able to interface to the system with no modification. All IPS sites will thus be able to receive the message and IPS are willing to have their users install and operate the system. Torex PLC's flagship product Torex Synergy will be capable of interfacing to the system via a Torex supplied API. Interfaces also exist for Torex System 5.7 and System 6000. The current interface to the various EMIS systems is not considered to be robust enough for long term strategic use. EMIS have confirmed that if the message achieves national standard status they would develop a fully integrated interface to the system. GP OOH systems suppliers Adastra is the dominant market supplier to GP OOH and deputising services having acquired Owl software earlier this year. Their two systems, Adastra and Night Owl represent 95% of the co-ops that are computerised. Adastra have been partners to the applicant since 1996. Night Owl had developed an interface to the system prior to their acquisition earlier this year by Adastra. The system interfaces to both these products. Adastra have always funded these developments internally. Thus virtually all computerised GP Co-operatives already have enabled software in place. GP Surgeries Each surgery would need to have the system installed. This has been proven to be possible remotely (the practice is e-mailed a zipped installation) and training materials are available within the application as well as on line. Training takes 1 hour. Costs Local level There are approximately 200 GP co-operatives that are computerised. Virtually all of these already have links enabled software in place. However some of these may need a comms server installed and a connection to NHS net established. The NHS net connections are funded via the NHS net program. The comms servers could be any
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reasonable specified PC costing £2-3,000 in the first year with a £1,000 annual maintenance fee thereafter. Approximately 10,000 GP surgeries would need installations of the system at £500 per year (this compares favourably with current costs for the pathology message software). The installed system would be able to receive NHS Direct messages as well and at no extra cost. Currently the costs to individual surgeries and GP Co-operatives are met either by the organisation themselves (approximately 50% of GP surgeries fund the system themselves); from the Out of Hours Development Fund or from PCT IT budgets. The service would require a team to manage the practice installations during office hours. National costs There are no required national infrastructure costs to implement OOH to GP messaging. The nature of OOH to GP messaging is that 90% of the messages will be for local distribution and thus can be safely handled on existing networks. However there is an opportunity to link this at a national level to developments around NHS Direct and for that reason this section is copied from the NHS Direct to GP Messaging requirement document. Because no detailed national implementation plan exists these costs have been scaled up from cost projections derived from modelling work undertaken in preparation for the projects HRI ERDIP bid. NHS direct will soon co-ordinate all of its call centres from 2 national data centres, each of these would need an interface and considering the annual volume of calls these would need to be corporate standard mirrored servers and would only provide message queuing. Annual costs of such machines would be in the region of £100K based on high street license costs (the NHS should be able to negotiate significant savings on these). These would radiate messages to a network of 15 – 30 regional message servers probably situated at Strategic Health Authority level again at a cost of £50-100K each annually. These regional servers would incorporate message stores to allow practices to collect messages accumulated whilst they are closed. No funding is currently identified to meet these needs.
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Support from the NHS, Social Service groups and suppliers likely to be effected by the development and implementation of the standard
There is clear and manifest evidence of support from the planners, managers and workers of the NHS. We can report that; 1. See above for support from the GP system supplier and OOH suppliers. 2. See also elements of the section on establishing the requirement. 3. This application is supported by the EDRDIP Evaluation board and the system was selected by the ERDIP program board because the development of this standard was a key element of the PID. 4. The 4 GP Co-operatives that cover Bristol have applied to the NHSIA to have the system installed. 5. Pilot funding has been secured to install 10 additional sites in North London under the London wide PKI scheme. 6. The Merton & Sutton and Wandsworth PCTs have indicated that this system is their preferred means of achieving compliance with the Carsen review. 7. Thamesdoc, a large GP Co-op with 400+ members has begun installing the system in all of its 120+ practices. 8. The system is currently bidding to assist in the work of the HRI program.
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Provide details of the funded development plan to move from a requirement to a draft standard.
This is not relevant to this application, the message is already operational and there is no need for a development plan to move from the requirement alone. There is a need for an implementation plan to support the move from draft standard to standard status.
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