INFORMATION MANAGEMENT AND TECHNOLOGY IN GENERAL PRACTICE

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					        INFORMATION MANAGEMENT AND
       TECHNOLOGY IN GENERAL PRACTICE
                                FEBRUARY 2005
                    THIS REPLACES THE VERSION DATED MARCH 2003

                     RCGP INFORMATION SHEET No7

This Information Sheet is copyright free, copies may be made as required

INTRODUCTION

Basic computerisation of practices is now virtually universal. This document will focus upon the
development of computing functionality and particularly those components which contribute to the
wide-scale realisation of the “paperless practice”. Important documentation, initiatives, tools and
organisations will be signposted to give an introductory overview of this complex area.

I. REASONS FOR COMPUTERISATION

The ongoing computerisation of general practice has occurred due to a mixture of government
reforms and incentives, personal and practice-based administrative benefits and societal
expectations. Some of these are outlined below:

•   From 1987 the Computer Reimbursement Scheme allowed Health Authorities to directly
    reimburse a proportion of the costs incurred by a GP in: purchasing or upgrading computer
    equipment; leasing a computer system; maintaining associated hardware/software; and
    paying staff costs associated with setting up. Under the new GP Contract (April 2004)1,
    primary care organisation (PCOs) rather than practices are responsible in full for funding the
    purchase, maintenance, future upgrades and running costs of integrated IT systems, as well as
    telecommunications links to branch surgeries and other NHS infrastructure and services.
    Ownership of practice IM&T systems has migrated to the PCO.

•   Computerisation conferred administrative benefits within the practice such as Items of Service
    claims management, prescription administration, finance, patient registration and electronic
    appointment systems. Most practices are already paperless in relation to patient registrations,
    Items of Service (IOS) claims, prescribing and, for most, pathology results.

•   There is a need to obtain validated population based data from GPs to ensure that services are
    commissioned appropriately. Under the new GMS contract, quality payments to practices are
    defined by attainment of various “quality indicators”. In order to fulfil these, and other new
    contractual obligations, practices need to enter and retrieve high quality information from
    practice systems.

•   The attainment of health promotion targets, both in response to financial incentives and to
    support the implementation of National Service Frameworks, is difficult to demonstrate without
    the use of IT.

•   The concept of clinical governance, introduced in The New NHS: Modern Dependable2, with its
    emphasis on quality of care and the need to quantify service indicators, relies upon consistent
    data entry, extraction and manipulation, synonymous with electronic systems. It is likely that
    future processes for re-licensing of individual GPs will require a robust body of clinical
    governance evidence harvested from electronic systems.

•   In October 2000 the Government removed the legal requirement for paper-based records,
    allowing GPs to legitimately become paperless, subject to meeting conditions to be established
    by local health authorities3. As a result of Shifting the Balance of Power4, and in accordance
    with Schedule 5 of the NHS Reform and Healthcare Professions Act 20025, with effect from
    October 2002 this approval process transferred to PCTs. Under the new GMS contract, the
    provision, rather than the approval of systems with adequate functionality in respect of
    electronic patient records (EPRs), shifted to the PCT.

•   Computerisation is expected to deliver the seamless care pathway envisaged by Government
    and synonymous with the concept of the patient as consumer - characterised by convenient



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   access to services and information, and reliant upon effective clinical communication systems.
   As the NHS Plan6 states “step by step over the next ten years the NHS must be redesigned to
   be patient-centred – to offer personalised services.”

II. GOVERNMENT IM&T POLICY FOR THE NEW NHS

A. OVERVIEW

In October 1998, the Government launched a strategy, Information for Health7, intended to ensure
that the NHS exploited the potential of information technologies in order to improve health
services. The Government’s stated objective was to “Deliver a lifelong electronic health record for
every person in the country, online 24 hour access to records and information about best clinical
practice for all NHS clinicians, full use of the NHS information highway for electronic
communication between every general practice and every hospital, increased public access to
information and services, through online, or telephone services and new ways of delivering
services and care through telemedicine or telecare.” In particular it identified the primary care
electronic patient record (EPR) as the “centre of gravity” for entry of all community health care
information and that data collection should be as a “byproduct” of the clinical entry.

The targets set within Information for Health were ambiguous but the NHS Plan (2000) and
Building the Information Core (2001)8 refined and modified these providing a clearer focus on
priorities and detailing delivery. The Wanless Report9, published in April 2002, also contained key
recommendations for IT in the NHS. These included a doubling and protecting of IT spend;
stringent and centrally managed national standards for data and the better management of IT
implementation in the NHS, including a national programme.

Delivering 21st Century IT Support for the NHS (2002)10 refined the information strategy, focusing
attention on fewer targets and taking greater control over the specification, procurement, resource
management, performance management and delivery of the information and IT agenda. Most
importantly it set out the scope and strategy for the National Programme for IT (NPfIT), formally
established in October 2002 with Richard Granger’s appointment as the Director General of NHS
IT. Over the next few years the NPfIT will oversee the implementation of: Contact systems; NHS
Care Records Service; Choose and Book; Electronic Transmission of Prescriptions; the new N3
National Network; and Picture Archiving and Communications Systems (PACS)

The new GMS contract witnessed a key shift by defining GPs as stakeholders in information
provision rather than mere users of services and technology. It stated that: “Future information
systems in primary care will be based on integration at a community level and on the concept of
GPs receiving an IT service rather than simply being provided with hardware and software. The
national IM&T programmes will be responsible for developing these arrangements and ensuring
that all key stakeholders, especially clinicians, are fully involved in determining appropriate
standards and methods of provision”.

B. FUNDING

The UK GMS contract provides for the total funding of the purchase, maintenance, future
upgrades, running costs of integrated systems as well as telecommunications links to branch
surgeries and other NHS infrastructure and services. PCOs have been asked to meet practices’
entitlements under the new contract, and in doing so, will be expected to use their unified
budgets.

In England this will be supplemented by the National Programme for IT (NPfIT) in the NHS, which
will provide an overall investment of £2.3 billion over three years (2004/3 £370 million; 2004/5;
£730 million; 2005/6; £1.2 billion) in NHS systems and infrastructure, above the £805 million
baseline spend on IT within the NHS. NHS budgets are set to increase year on year and there will
be increased spending on IT rising from the current 1.8% of total NHS spend to 4% of total spend
by 2008, as recommended in the Wanless Report.

C. RESPONSIBILITIES

The key organisations and the areas of responsibility associated with delivering the IM&T strategy
for the NHS are set out below:

a) The National Programme for IT (NPfIT) is led by the Director General for NHS IT (Director
   General) at the head of an organisation comprising a co-located, integrated team of DH, NHS,



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     secondees, and contractor personnel. The Director is responsible for IT contracts, IT solutions
     and installation; and for providing the expertise to the NHS. The Director of Service
     Implementation ensures effective patient, clinical and management engagement and
     communication, and works closely with national clinical champions. Currently these include
     Professor Mike Pringle (FRCGP) and Dr Gillian Braunold (MRCGP) who will be representing
     general practice in the implementation process.

b) The Care Record Development Board (CRDB) brings together patients and service users, the
   public, and social and healthcare professionals within a single forum that will identify the
   values, principles and processes of care and ensure that these are taken into account in the
   implementation of systems for NHS and social care. It will work with NPfIT to enable sharing of
   information, scheduling and processes across traditional boundaries.

c)   The NHS Information Authority delivers some administrative services for NPfIT. It has a remit
     to improve patient care and achieve best value for money by working with NHS professionals,
     suppliers, academics and others to provide national products, services and standards. It is also
     responsible for information and knowledge services (such as the National electronic Library);
     the definition of data and data exchange standards; the development of data security,
     confidentiality and consent advice; clinical messaging services; and, core national systems
     specifications for electronic patient records, e-prescription services, booking services, and the
     health record service.

d) At regional level the Chief Information Officer appointed by StHAs will ensure that there is
   funding and effective IT management for every PCT and NHS Trust to implement and use the
   core IT solutions determined at national level.

e) At local level Primary Care Trusts are responsible for: maintaining information quality and
   flow; implementing national standard data, data interchange and standard specification
   systems from a limited portfolio of choices; accessing and using national IT services (Health
   Service Record, Bookings Service etc); meeting targets of infrastructure improvement; and,
   changing working practices to gain the benefits offered by the new IT services and software.
   Under the new GMS contract, PCTs became responsible for the funding of the IM&T
   infrastructure and as well as the initial and continuing education, support and training of staff
   in the use of IT.

D. TARGETS

Specific national targets for IM&T in the NHS have been modified and refined over recent years
and across several Government papers. The table below attempts to summarise and collate this
information for those targets pertinent to primary care:

 Requirement                                            Target Date

 National bookings service implemented with all         December 2005
 patients in England able to choose and book a
 first outpatient appointment.

 Picture Archiving and Communications Systems           March 2007
 (PACS) fully implemented.

 Migration of all 18,000 NHS sites from NHSnet          May 2007
 to N3 network.

 Common clinical terms established for                  December 2007
 hospital/primary care

 Electronic transmission of prescriptions and           December 2007
 dispensing information between prescribers,
 community pharmacists and re-imbursement
 authorities. Record of prescription/dispensing
 added to NHS Care Record Service.

 NHS Care Records Service:

 Ability of health and care professionals to view       Summer 2005



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 basic patient information.

 Access to more detailed patient records; ability       Summer 2006
 to make electronic requests and orders for
 diagnostic images and pathology; and ability to
 be notified or emergency and out-of-hours
 encounters.

 Additional decision-making support for doctors         2006-2008
 and nurses; care at home helped by links to
 healthcare professionals anywhere in the
 community; better healthcare planning based on
 data held on NHS CRS.

 Full integration of health and social care systems     2010
 in England.

III. INFORMATION MANAGEMENT AND TECHNOLOGY UNDER THE NEW GMS CONTRACT

A. OVERVIEW

Under the new GMS contract PCTs will fund the purchase, maintenance, upgrade and running costs
of systems, infrastructure and IT services. PCTs will own these systems and be responsible for
their maintenance. The change in ownership reflects the importance of IT in delivering the new
contract – from allocations, through to monitoring and payments. Surprisingly GMS practices are
not obliged to use computer systems, but the effort involved in maintaining paper records will
prove punitive in the successful capturing of clinical quality data.

Paramount to the success of the new contract is that practice systems are capable of capturing,
analysing and reporting in line with the Quality and Outcomes Framework (QOF). In many respects
the information that needs to be collected is no different to that which practices were already
recording as part of electronic patient record, such as disease registers. Developed as part of NPfIT
the Quality Management and Analysis System (QMAS) is a new single, national IT system, which
gives GP practices and PCTs objective evidence and feedback on the quality of care delivered to
patients. The system shows how well each practice is doing, measured against national
achievement and prevalence targets. QMAS training is available at: nww.qmastraining.nhs.uk

Where the practice is not as advanced, PCTs are responsible for ensuring that practice systems are
upgraded with templates and software for recording and monitoring quality indicators; and with
new data extraction functionality and a way of transferring information to PCTs. It is important for
practices to implement consistent clinical coding using Read codes or SNOMED CT.

B. CHOICE OF SYSTEMS

A practice is entitled to choose or be upgraded to any accredited system, as long as they support
this with a justifiable business case. Accredited denotes an RFA 99v1.x system in England,
Northern Ireland and Wales, and a RFA Scotland v.1 system in Scotland. IM&T services will be
delivered to the practice based on a Service Level Agreement (SLA) setting out in detail the
responsibilities of the system suppliers. Practices will receive hardware and software upgrades
from their supplier in a rolling programme as specified in their SLA.

The PCO’s role is to support the practice in this process and to fully fund the purchase of the
chosen new system. If a practice has an accredited system, the practice can ask for it to be
replaced or changed but the practice is not expected to do this more than every three years. By
means of direct provision all GPs will be provided with software systems that allow them to
interrogate their clinical databases in order to report on their QOF achievements. These systems
will be validated and approved nationally and can be provided by prime suppliers or by third
parties. Liability issues will be fully managed by the PCT in line with local agreements with
practices and with UK national service level agreements with suppliers removing the responsibility
from the GP.

The NPfIT is responsible for developing functional specifications for systems, accrediting systems
against national standards, and for involving GPs in the development of these new systems. The
GPC/RCGP Joint GP IT Committee has been nominated to provide an effective stakeholder and




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specification group to assess these new systems on fitness for purpose and provide guarantees on
security and confidentiality. It issued a joint statement in 2004 which confirmed that:

    •   GPs will not be forced to move to any system that has functionality that is less than their
        existing system.
    •   Moves to new systems will not be contemplated until data migration issues have been
        resolved.

C. TRAINING

PCTs will manage and fund IT education and training for practices often via the advice or active
facilitation of Primary Care Information Services (PRIMIS). Training should be based on a Training
Needs Assessment and will typically cover: the use of READ coding and browsers; classifications
and nomenclatures; understanding good data recording and storage practice; legitimate use of
aggregated data and associated security and confidentiality issues; developing disease registers;
recording reliable morbidity data; how to improve data quality; how to ensure GPs can be paid
correctly under the new contract. PCOs have been advised to pool IT skills and resources, for
example by making better use of IT staff employed by individual practices, and are expected to
ensure that local health informatics services are effectively engaged to support the agenda.


 Information Management and Technology – NHS Confederation Briefing Note
 http://www.nhsconfed.org/docs/gmsbriefing4.pdf
 Choice of Nationally Accredited Systems – BMA Guidance Note
 http://www.bma.org.uk/ap.nsf/Content/focusonchoice0204/$file/Focusonchoice.pdf
 Quality Management and Analysis System - NPfIT Guidance Note
 http://www.dh.gov.uk/assetRoot/04/08/19/24/04081924.pdf


IV. ELECTRONIC PATIENT RECORDS AND THE NHS CARE RECORD SERVICE

A. DEFINITIONS

The concept of “paperlessness” is self-defining. It is the replacement of all paper-based and
manual systems with an electronic equivalent. Obviously many office-based administrative
procedures have been mechanised incrementally over the years but the central concern of
achieving paperlessness is the storage of clinical patient-based information in electronic systems
so as to achieve the associated benefits of the space conservation, accessibility, standardisation,
manipulation, extraction and collation of information. The paperless practice is linked inextricably
with the electronic patient record (EPR) in that “a paperless practice is one that records all medical
records and prescribing on an EPR” and in which “all referrals and test results are recorded or
generated from within the EPR”11.

The EPR is a record of care provided mainly by one organisation, for example a practice or
periodically an acute hospital. Most NHS locations hold electronic patient records that are
accessible locally but the information cannot currently be transferred across the system. A core
component of NPfIT the NHS Care Record Service (NHS CRS), previously known as the Integrated
Care Record Service (ICRS), is an electronic integrated record management system, contracted to
BT for the next 10 years, that will digitalise 50 million patient records and allow information to be
shared across the NHS.

The core of the new service will be the NHS Care Record Spine - a nationally provided sub-system
hosting a summary healthcare record for every person in England across care disciplines and over
time. In effect it is a longitudinal record of a patients’ health and health care from cradle to grave
combining both information about patient contacts with primary health care with subsets of
information associated with the outcomes of periodic care held in other EPRs. In short,
organisational records will become EPRs and a subset of them will interface with and contribute to
a lifelong record of a patient’s health and healthcare – the Care Record. The information held on
the Spine will include: NHS Number; date of birth; name and address; allergies; adverse drug
reactions; and major treatment that has been provided, is continuing, or has been completed.

B. POTENTIAL BENEFITS

The successful implementation of electronic health records will mean that patient information will
no longer be fragmented and inconsistent; records will no longer be accessible solely to one



                                                  5
person at one time in one place; and, errors of misfiling and misreading will be eradicated. The
rapid sharing of information between teams is essential as diagnosis and treatment of conditions is
becoming increasingly specialised and can involve groups of organisations and personnel working
in co-operation. In terms of patient safety there will be more timely information available to
prevent possible conflicts in prescribing and treatment.

Records management procedures should become less bureaucratic, with reduced administration
and less duplication of record-keeping, as well as more efficient and appropriate referrals and
communications of test results and discharge summaries between GPs and hospitals. Additionally
patients will have simpler access to their own records.

C. ISSUES

The plans for the NHS Care Record Service has raised several vital issues, most particularly, those
of compliance, consent and data integration and integrity:

i) Compliance

NPfIT supports the principle that no practice should move from current solutions until the NHS CRS
solution has the same or greater levels of functionality than GPs currently enjoy. The GPC
recognises and supports the need for transition over time to the new NHS CRS solution, but are
keen not to see practices 'forced' into a 'double' migration. However, the National Programme does
warn that from January 2005 practices that have chosen not to "join" NPfIT, by not taking on the
full range of services and benefits available, will become increasingly disadvantaged in comparison
to fully integrated practices. They will lack access to records and services (such as Choose and
Book) that the vast majority will enjoy and they will increasingly find themselves unable to
practice fully and efficiently without NPfIT enablement.

The RCGP Health Informatics Group advised in 200312 that before signing up to its use, the
profession needs to be satisfied that the information held on the NHS Spine is appropriate, that it
is fit for purpose, and that it will not endanger patient safety.

ii) Consent and Confidentiality

The RCGP Health Informatics Group further advises that automatic transmission of information
from local clinical systems to the national NHS Spine, outside of any control by health care
professional or patient, raises serious ethical concerns because it would be impossible to obtain
properly informed consent prior to exporting the data. Additionally, any secondary processing of
information on the NHS Spine should be subject to the same constraints and legal controls (e.g. in
relation to the 1998 Data Protection Act) as any other secondary processing of clinical information
elsewhere. Under no circumstances should it be given Section 60 exemption.

NPfIT contend that the National Care Record Service guarantees “absolute confidentiality of care
records through the unique NHS number, password protection, and a trail of any access (i.e.by
whom, when and where) attached to a record.” The NHS Care Records Service (NHS CRS) will only
be available to healthcare professionals with a legitimate relationship to a particular patient. A
record will be kept of everyone who accesses a patient's record and alerts will be raised if anyone
tries to access a record in contravention of predetermined system rules. Inappropriate use of
health records or abuse of computer systems may lead to disciplinary measures, bringing into
question professional registration and possibly legal proceedings.

iii) Integration

The NPfIT aims to ensure that new systems, subject to local NHS priorities and plans, integrate
and inter-operate with existing systems. It is working closely with GP system suppliers to achieve
Choose and Book compliance, including the need to integrate with the Spine, and good progress
has been achieved. Contractual arrangements between all GP system suppliers and the LSPs have
not yet been finalised and the Programme cannot therefore indicate the levels of integration that
will be achieved over time. In the long-term practice systems may need to be changed and NPfIT
recognises the risk associated with subsequent data migration.

The RCGP Health Informatics Group advises that the integrity of information held on existing
systems must not be damaged through any of the actions related to implementation of ICRS and
the NHS Spine.




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D. CLINICAL SYSTEMS

There are about 10 GP systems suppliers in the UK but just three suppliers (EMIS, In Practice
Systems and Torex (iSoft)) dominate the market with a 90% share, a figure that has risen 5% in
the last three years (see table below for current market share in England). Going Paperless – a
Guide to Computerisation in Primary Care includes an overview of these systems in Appendix 513.
The websites of major system suppliers and their associated user-groups can be viewed at:
http://www.primis.nhs.uk/pages/System_Suppliers_and_User_Groups.asp

 GP Clinical System Supplier            No of Practices      Market Share
                                           Supplied

 No GP Clinical System                         243                   2.8
 Chime UCL Medical School                        6                   0.1
 EMIS Ltd                                     5157                   58.5
 Healthy Systems Software                       37                    0.4
 In Practice Systems Ltd                      1514                   17.2
 Torex (iSoft)                                1278                   14.5
 Microtest Ltd                                 184                   2.1
 Protechnic Exeter Ltd                         103                   1.2
 Seetec                                         87                   1.0
 The Computer Room                             22                    0.2
 Phoenix Partnership                           179                   2.0

 Total                                        8810                   100

Source: NHSIA Website: GP Clinical System Supplier Rollout Status:
http://www.nhsia.nhs.uk/sat/testing/pages/gp_clinical.asp

The NHSIA Standards Enforcement in Procurement (STEP) programme gives GPs, health
organisations and suppliers advice on IT procurement via its STEP Version 10, which is fully
aligned with NPfIT.

Standards Enforcement in Procurement (STEP): http://www.nhsia.nhs.uk/step/pages/

E. CORE ELEMENTS OF THE EPR

The basic components of an EPR, as envisaged by Guidelines for General Practice Electronic Patient
Records (Version 3), must be capable of delivering the following clinical functionality:

    •    Assist the clinician to structure his or her thoughts and make appropriate decisions.
    •    Act as an aide memoir for the clinician during subsequent consultations.
    •    Make information available to others with access to the same record system who are
         involved in the care of the same patient.
    •    Provide information for inclusion in other documents (e.g. laboratory requests, referrals
         and medical reports).
    •    Store information received from other parties or organisations (e.g. laboratory results and
         letters from specialists).
    •    Be transferable to any NHS practice with which the patient subsequently registers.
    •    Provide information to patients about their health and health care.
    •    Assess the health needs of the practice population.
    •    Identify target groups and enable call and recall programmes
    •    Monitor the progress of health promotion initiatives.
    •    Provide patients with an opportunity to contribute to their records.
    •    Support medical audit.

The document also defined a number of non-clinical functions that would define a patient record
system that was fit for purpose:

    •    Provide medico-legal evidence (e.g. to defend against claims of negligence).
    •    Provide legal evidence in respect of claims by a patient against a third party (e.g. for
         injuries, occupational diseases and in respect of product liability).
    •    Meet the requirements of specific legislation on subject access to personal data and
         medical records.




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    •    Record the preferences of patients in respect of access to and disclosure of information
         they have provided in confidence.
    •    Provide evidence of workload within a practice to the PCO.
    •    Enable commissioning of community and secondary healthcare services.

The table below identifies characteristics that may be identified with different levels of
paperlessness within a practice and can be used a quick checklist. Most of the core elements
described in this table will be described later in this document.

 Level of Computerisation              Typical Features in Place

 Have mainly or solely a paper-        •    Morbidity register
 based system                          •    Manual call/recall system
                                       •    Considering/committed to computerisation

 Office based IT system being          •    Age/sex register and prescribing
 used systematically                   •    Some templates used and populated with baseline data
                                       •    Ability to run searches on prescribing to generate morbidity lists
                                       •    Standardised coding of morbidity and interventions
                                       •    Electronic appointment booking system

 Desk-top IT being routinely           •    Detailed computerised patient information
 utilised (but not yet paper-          •    Clinical records summarised and available to whole primary health
 light)                                     care team (PHCT)
                                       •    Clinicians trained to use system
                                       •    Consultation recording (during or post event)
                                       •    Single data entry for PHCT, based on agreed templates/protocols
                                       •    Use of PRODIGY (or other decision support tool)
                                       •    Working towards standardised READ coding
                                       •    PRIMIS in use and supporting NSF development through use of
                                            templates
                                       •    Standardised extraction tools in use
                                       •    Electronic appointment booking system includes appointments with
                                            community team
                                       •    Access to knowledge base via web

 Have achieved                         •    “Paperless” consultations (consistent and appropriate use of Read
 paperlight/paperless system                coding across PHCT during consultation in accordance with agreed
                                            guidelines)
                                       •    Incoming pathology data captured using standard coding
                                       •    Electronic referrals
                                       •    Electronic discharge summaries
                                       •    Record transfer GP to GP (not possible at present)
                                       •    Data quality standards monitored using MIQUEST
                                       •    Information systems that support continuous audit/quality
                                            improvement

Source: NeLH Improving IT Competence:
http://www.nelh.nhs.uk/nsf/inprimarycare/information_systems/improving_competence.htm

F. STANDARDS AND GUIDANCE

i) Approval

Until the advent of the new GMS contract GPs needed to seek approval from their PCO to maintain
records in an electronic format. Under the new GMS contract (April 1st 2004), the responsibility for
provision, rather than the approval of systems with adequate functionality in respect of EPR, is
shifted to the PCT.

ii) Rules

Section 3.2 of Standards in Collection of Health Data from General Practice Guidelines14 defines
several rules to consider when maintaining electronic patient records:




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•    Remember that the purpose of the electronic recording is to support patient care.
•    All members of the team must take part in recording.
•    All recording must be consistent and each episode of illness should only have one code.
•    Regular feedback and audit of the process must be conducted. Audits on a quarterly basis are
     recommended for at least the first two years after a practice decides to go paperless.
•    All contact with patients must be recorded.

iii) Guidelines

The definitive guidance for EPR in general practice is contained within the document Good Practice
Guidelines for General Practice Electronic Patient Records (Version 3)15. This document – prepared
by the RCGP, GPC and DH – defines standards for electronic patient record keeping, migration and
transfer; describes the characteristics of records; and explores issues of ownership, security,
consent, and information governance. A vital update to the latest version of the document was the
clarification of issues around retention; summarisation; shredding and scanning of records, which
is contained in Chapter 6. These issues had proved highly contentious prior to the new guidance.

Good Practice Guidelines for General Practice Electronic Patient Records (version 3):
http://www.dh.gov.uk/assetRoot/04/06/97/65/04069765.pdf

iv) SAT and Requirements for Accreditation (RFA)

The System Accreditation and Testing (SAT) Programme aims to ensure that IT solutions for use in
the NHS meet the specified requirements levels and are both clinically and technically safe to use.
The current activities include: testing services for GP systems to support RFA99v1.2 and testing
services for the new GMS contract.

The functionality of clinical systems, particularly in terms of the electronic extraction of data from
the EPR, is controlled by the Primary Care Computing Systems Requirements for Accreditation
(RFA) which was first introduced in 1993. The most current version of this is RFA 99 v1.2
(DTS/Nurse Prescribing) which was published by the NHS Information Authority in August 2003.
This specifies the core requirements which all GP systems should be capable of performing and is a
way of influencing the development of GP computing. These requirements became more binding in
March 2000 when health authorities were informed that they should restrict the direct
reimbursement of GP computer costs to those systems that were accredited as meeting RFA99
standards16. The main sections of RFA are:

•    Core requirements including privacy, security, Read Codes, NHS Number, data standards and
     system configuration.
•    Support and training.
•    General functionality including patient and practice administration, prescribing and
     dispensing.
•    Message and information exchange including connection to NHSnet and electronic data
     interchange (EDI) requirements such as HA/GP links and pathology reports.
•    Knowledge related functionality including MIQUEST and Prodigy.

RFA99: http://www.nhsia.nhs.uk/napps/rfatest/pages/default.asp

Under the new GMS contract every practice in the UK has the choice of RFA-accredited systems.
The contract states that systems must enable:

•    Clinicians to access appropriate information about individual patients held on other systems.
•    Users to interrogate and maintain individual patients’ electronic health records with
     appropriate confidentiality safeguards.
•    Inter-communication between clinical and administrative systems.
•    Remote access to research papers, reviews, guidelines and protocols via the Internet and
     NHSnet.
•    Health professionals to access the knowledge base of healthcare at the point of patient
     contact.
•    Dispensing practices to have synchronous links.
•    The development of a framework for electronic prescribing.




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V. ACCESS TO INFORMATION

A. NHSNET AND N3

Until 2004 NHSnet provided the networked infrastructure facilitating the Government’s IM&T
strategy. In February 2004 BT was awarded a contract to provide and manage a broadband
network to link all NHS organisations in England. The New National Network, also known as N3
replaces NHSnet, enabling transfer of voice and video information, as well as data, including
emails, medical information, test results and GP payment information. It will provide the network
on which to run the new IT systems being delivered by NPfIT, and make the NHS the first major
user of significant broadband capacity in the public sector. The number of sites served will be
increased from 10,000 - under the current NHSnet contract - to all 18,000 NHS locations and sites.
N3 Developments: http://www.n3.nhs.uk

Contact is a secure national email and directory service developed by the NHS with Cable and
Wireless. It is provided free of charge for NHS staff and developed specifically to meet BMA
requirements for clinical email between NHS organisations. It comprises a national directory of
people in the NHS, containing the name, email addresses, telephone numbers, name and address
of their NHS organisation, and information about departments, job roles and specialities. It also
provides email addresses “for life”, in that the address stays with the individual as they move
around the NHS. Eventually it is designed to replace paper communications like: patient referrals
from GP to hospital; discharge letters; clinical enquiries; research links and clinical team
communications.

B. ELECTRONIC BOOKINGS

In August 2004 the DH published Choose & Book: Patient’s Choice of Hospital and Booked
Appointment17 a document which outlined how the NHS would fulfil the pledges made in the NHS
Improvement Plan - which set out NHS priorities until 200818. The electronic appointment booking
service – now known as Choose and Book and contracted to Atos Origin – would, by December
2005, ensure that all patients needing a referral to hospital could expect:

   •   To be offered a choice of 4-5 hospitals or suitable alternative providers.
   •   To be able to book their appointment with their preferred hospital/suitable alternative
       provider, with information made available locally to inform their choice.
   •   To be supported in making their choice by their GP or primary care professional and,
       where necessary, by a range of practice, PCT and community and voluntary sector based
       services.
   •   PCTs will provide targeted packages of support designed to ensure that all patients,
       including hard to reach patients and communities, can benefit from choice
   •   Aftercare and rehabilitation to be provided locally following any hospital treatment.

Where patients are unhappy with the care offered by their chosen provider they will be able to
return to their GP in order to make another choice.

i) Progress

A 2005 National Audit Office (NAO) report - Patient Choice at the Point of GP Referral19 – endorsed
the Electronic Booking Service as the most effective way of delivering the Government’s Choose
and Book agenda, but highlighted the continued scepticism of GPs and the unrealistic nature of
roll-out deadlines. The report welcomed the substantial progress made via organisational change,
new or modified IT systems, and the provision of support to NHS organisations. It felt that Atos
Origin had delivered a functioning system; with the first e-booking made in July 2004. The system
will be linked to upgraded or new Patient Administration Systems in hospitals and IT systems in
GPs’ surgeries to provide the overall service known as e-booking. The roll-out of changes to
hospital systems to allow them to link to e-booking is gathering pace and four types of GP systems
can now link to e-booking. A DH team is working with the three main existing GP system suppliers
(including the largest EMIS) to agree, by February 2005, a deployment schedule.

ii) Obstacles:

The roll-out of e-booking has been slower than planned and at the end of December 2004 only 63
bookings had been made, due to unreliable end-to-end systems, limited progress in linking to GP
and hospital systems, and the limited number of GPs willing to use the system. According to the
NAO report, on present plans only 60-70% of the NHS will have Choose and Book available by



                                                10
December 2005. The DH has recently appointed a new National Implementation Director for
Choose and Book and has asked the NHS to plan how to deliver choice even where Choose and
Book is not yet deployed. This would use interim IT systems which are planned to be available by
the end of May 2005.

The NAO survey of GPs found that around half of GPs know very little about e-booking and 61%
feel negative about the initiative. GPs’ concerns include practice capacity, workload, consultation
length and fears that existing health inequalities will be exacerbated. The DH has held back on its
main effort to inform and engage GPs about choice until it has had a working e-booking system to
show GPs, but it intends to mount a campaign to inform and engage GPs during 2005.

Just over a quarter of PCTs currently forecast that they will not achieve the choice targets, and two
thirds have yet to commission the required number of providers. The DH is developing a
framework of support to help trusts overcome these obstacles, and this week also announced that
PCTs which successfully offer a choice of hospital treatment to NHS patients through the electronic
Choose and Book system will be rewarded under a new three stage £95 million incentive scheme.

iii) Recommendations:

The NAO report recommended that the DH should:

    •   Urgently address the low level of GP support for their plans by supplying GPs with more
        information. It should regularly monitor GP views.
    •   Keep under regular review the implementation of choice, and of the interim solutions. It
        should ensure that the implementation of interim solutions does not detract from the
        priority of bringing in fully integrated e-booking systems.
    •   Establish an evaluation framework for PCT commissioning to assist SHAs in assessing their
        capacity and skills in this area and securing improvements where necessary.

Choose and Book:
https://www.healthspace.nhs.uk/chooseandbook/

VI. KNOWLEDGE MANAGEMENT

A. NATIONAL ELECTRONIC LIBRARY FOR HEALTH (NELH)

The NeLH provides access to the best current knowledge available for improving healthcare,
clinical practice and patient choice. It forms the cornerstone of the plan to establish a national
knowledge service by December 2007. NeLH is divided into specialist clinical areas which act as
virtual branch libraries. One of these focuses on primary care:
http://www.nelh.nhs.uk/primarycare/

The NeLH is in the final stages of commissioning a new Primary Care Information Service which is
due to be launched in 2006. The new service will provide access to common core knowledge: a
Clinical Question and Answering service; Policy, Quality and Safety briefings; and a Primary Care
Knowledge Base. The RCGP has launched a GP Guidance database which is available at:
http://www.rcgp.org.uk/information/gpdatabase/?menuid=17

B. NHS-UK

NHS.uk is the official national website for the NHS and gateway to all NHS organisations on the
Internet, providing NHS staff and the public with information about the NHS both at local and
national level, including directories of all NHS organisations and the services they offer. It also
contains comprehensive careers and NHS job vacancies information; as well as providing the
Healthspace service (a secure place on the internet where patients can store personal health
information), and the platform for the Book and Choose initiative.

NHS-UK site: http://www.nhs.uk/

C. PRODIGY

PRODIGY is an online clinical decision support system for GPs. It is a mandatory component of
RFA99, requiring that it be fully integrated into accredited clinical systems for use during
consultations. In addition to evidence-based prescribing support it offers specific non-drug advice,




                                                 11
patient information leaflets and recommendations on referral. It contains a wealth of clinical
background information for use outside the consultation as either reference or learning material.

Some doctors feel that clinical decision support systems reduce the clinical autonomy of GPs while
others feel that it aids, rather than replaces, the decision making process. As mandatory
components of accredited systems, and because of the NHS Plan target of having the majority of
NHS staff working according to protocols for common conditions, tools supporting homogeneity
during consultation will become more widely used.

PRODIGY: http://www.prodigy.nhs.uk/

D. HEALTH INFORMATICS

The Health Informatics Unit is a specialist team within the NHS Information Authority’s directorate
of healthcare information and knowledge. The Unit is taking a lead in developing health informatics
professionalism across the NHS; working with national partners to develop and stimulate an
increase in capability and capacity in health informatics. This will enable the NHS to plan,
implement, use, and share information and achieve maximum benefits from the introduction of
new information and IT systems.

Health Informatics Unit: http://www.nhsia.nhs.uk/informatics/pages/default.asp

VII. INFORMATION FOR PERSONAL HEALTH

A. CALDICOTT AND CONFIDENTIALITY

The opportunities that the N3 network provides for electronic communication of clinical information
requires caution in terms of confidentiality and security. The agreement between the NHS and DH,
the BMA and the clinical professions is that patient identifiable information should be encrypted
before being communicated over any external network. Automatic encryption during sending of
emails is part of the new Contact system and conforms to the Information Security Standards for
the NHS: http://www.nhsia.nhs.uk/security/pages/security_standards.asp

Every health organisation from PCT up is required to appoint a Caldicott Guardian whose role it is
to monitor the security and confidentiality of health information within their organisation and are a
good first port of call for a GP with uncertainties over information security, be it electronic or
paper. Information and Information Systems for Primary Care Organisations20 recommends that all
staff should receive guidance on information governance issues. Under the new GMS contract the
GPC specification group quality-assures new systems, therefore offering GPs vital guarantees on
security and confidentiality. Responsibility for these issues has been effectively removed from
practices, as liability will be covered by SLAs between PCTs and system suppliers.

Security and privacy are core requirements in RFA99 and are therefore mandatory in all accredited
GP clinical systems. Chapter 3 of Good Practice Guidelines for General Practice Electronic Records
(Version 3) covers the issues of security and authentication in the context of the EPR. A greater
sophistication of authentication procedures is possible in the future with proposed “smart cards”
for all authorised staff.

DH Information Governance Toolkit: http://nww.nhsia.nhs.uk/infogov/igt/

B. CLINICAL COMMUNICATIONS

i) Pathology and Radiology Reporting

Electronic data interchange (EDI), including pathology and radiology results messaging sent from
hospitals to GP practice systems, is one of the core functional elements of NHSnet. Pathology
Messaging implementation Project (PMIP) standards for information content, structure,
management and security of electronic pathology reports messaging between laboratories and GPs
have been implemented across the NHS. These standards predate those currently under
development within the National Programme for IT (NPfIT); the NHS IA is supporting the current
implementation and preparing the transition to NPfIT systems and standards.




                                                 12
 National Standard Pathology Reports: http://www.nhsia.nhs.uk/pathology/pages/default.asp
 Good Practice Guidance for the Use of Pathology Reports EDI for General Practice:
 http://www.nhsia.nhs.uk/pathology/pages/documents/gpgg_v1.005.pdf


ii) GP to GP Transfer of Records

The NHSIA GP to GP Communication Project started in June 2001 with a remit of developing
mechanisms for communicating EPRs between GP computer systems in the UK. The practice
administration, patient convenience, and clinical practice benefits of this initiative would be huge.
GP-to-GP transfer was successfully negotiated as a requirement of the new GMS contract which
stated that the: “key to the successful delivery of efficient and accurate data recording will be ease
of transfer of data between systems. The GP-to-GP record transfer project will enable clinical
information to be transferred from one clinical system to another without the need for re-keying.”
The project worked with three GP systems suppliers – EMIS, Torex, and In Practice – and
produced a version of the message required to transfer a fully structured patient record.

GP to GP Communication Project has since closed in 2004, with responsibility transferring to NPfIT.
The GPC has been continually pushing for clarification from the DH of when GP-to-GP transfer will
be available; and in response a group has been set up by the National Clinical Advisory Board to
advise on how to manage GP-to-GP transfer of records. It seems that the Spine will now be used
as the platform for GP-to-GP transfer.

iii) Picture Archiving and Communications Systems (PACS)

PACS was only made a core NPfIT service in 2004. Digital images will form an essential part of
every NHS patient's Care Record and are being introduced via the NHS Care Records Service. The
service will be rolled out gradually from Summer 2004 towards full implementation in 2007.

The service will capture, store, distribute and diplay static or moving digital images such as
electronic X-rays or scans, for more efficient diagnosis and treatment. It takes away any need to
print on film and to file or distribute images manually. The images can be sent and viewed across
all NHS locations. The capacity of diagnostic services will increase with PACS and test results and
diagnoses will be available more quickly.

Picture Archiving and Communications Systems (PACS):
http://www.npfit.nhs.uk/programmes/pacs/

C. CLINICAL TERMINOLOGY

Since 1980 all GP EPR systems have used clinical coding and READ Codes have been mandatory
within the RFA requirements. In Building the Information Core the Government set the target of
introducing SNOMED CT into clinical information systems by March 2003. It also stipulated that
after 1st April 2003 any computerised information system being developed to support any clinical
information system, such as EPRs, should use the NHS preferred terminology SNOMED CT.
Users/suppliers were advised not to develop new READ Code based systems from April 2003.

SNOMED CT (Systemised Nomenclature of Medicine Clinical Terms) combines the College of
American Pathologists SNOMED with Clinical Terms version 3 (READ Codes) to create a
comprehensive clinical terminology to support computerised patient records. The successful
development of EPR requires common coded clinical vocabulary to facilitate reliable and accurate
electronic communication of clinical information with nationally and internationally consistent
activity analysis. As the new terminology is a merger SNOMED CT will be completely compatible
with existing Read Codes. It is explicit in the User Requirements document that, in order for
SNOMED Clinical Terms to meet user needs, a mechanism will be in place to migrate legacy data.
The latest version of the clinical codes supporting clinical indicators in the Quality and Outcome
Framework (QOF) introduces the use of SNOMED Clinical Terms.


 SNOMED CT: http://www.nhsia.nhs.uk/snomed/pages/default.asp
 Clinical Terminology (READ Codes): http://www.nhsia.nhs.uk/terms/pages/default.asp




                                                 13
D. ELECTRONIC TRANSMISSION OF PRESCRIPTIONS (ETP)

Many administrative aspects of prescription management are already automated, including the
generation of prescriptions and endorsement by pharmacy computer systems. The future aim is to
deliver a service that will allow prescriptions generated by GPs (and other primary care
prescribers) to be transferred electronically between prescriber, dispenser and reimbursement
agency. Patient medication records held within the NHS Care Records Service (NHS CRS) will be
populated by information from local prescribing and dispensing systems connected to the ETP
service, integrating ETP with the NHS CRS.

The DH commissioned three pilots in 2002, to test different approaches to the ETP process. These
pilots closed at the end of June 2003 having established the technical viability of ETP. Since then
NPfIT has issued prescribing and dispensing specifications to system suppliers in order to enable
system development, and has engaged other stakeholders such as community pharmacists. ETP
compliant systems, connectivity and the accompanying ETP workflow are being considered as part
of the new contractual framework for community pharmacy. ETP will form part of essential
services, so consequently all community pharmacies under their NHS terms of service will need to
be able to provide dispensing via ETP.

ETP will be progressively rolled out from early 2005 and will be fully implemented by the end of
2007. It is envisaged that initial rollout of the ETP service will be via a small number of early
adopter sites, which are currently being identified.

i) How Does ETP Work?

ETP covers all primary care prescribing and dispensing (including repeat dispensing) and supply of
medicines, drugs, appliances and chemical reagents by an authorised dispensing contractor.
Prescribing systems will send electronic prescriptions to the ETP service as part of the overall NHS
CRS. The electronic prescription contains the prescribed medication items, and information about
the authorisation of repeatable prescriptions. When the electronic prescription is received by the
ETP service it becomes available for dispensing. At the same time, the prescribed medication
details are added to the patient’s NHS Care Record.

If the patient has nominated a particular pharmacy from which to receive their medication, a copy
of the electronic prescription is sent straight to that pharmacy. The patient can then either go to
the pharmacy to collect their medication or, if the pharmacy offers a home delivery service, the
patient may request the pharmacy to deliver the medication to their home. If the patient does not
nominate a specific pharmacy, they will be given an ePrescription token to present at a pharmacy.
This is likely to look quite similar to the existing prescription form, but will have a barcode printed
on it containing a unique number. This will enable the pharmacist to obtain details of the
prescription from the NHS CRS.

On presentation of the ePrescription token at a community pharmacy, the pharmacist will access
the NHS CRS Spine through their local dispensing system and request the prescription. The
dispensed medication information is sent to the ETP service and added to the patient’s NHS Care
Record. Once fully dispensed, the community pharmacist sends an electronic reimbursement
request to the ETP service detailing the dispensed medication and reimbursement claim
information. This is routed to the appropriate reimbursement agency (e.g. the PPA) for processing.

ii) Potential Benefits of ETP Service

By populating the patient’s medication record on the NHS CRS with prescribing and dispensing
information for the patient, healthcare professionals within different care settings can view a
patient’s medication history allowing the most suitable treatment to be administered. It will also
reduce transposition errors, missing information from prescriptions and adverse drug events.

ETP means patients will no longer need to attend their GP surgery to order and collect their repeat
prescriptions. It will also facilitate the development of new services for patients (such as home
delivery of medicines). Patients will also be able to choose where to collect a prescription

Prescription volume increased by 5.8% per annum to over 658 million items in the year to June
2004. It is therefore vital that ETP delivers efficiency gains for GP practices, community
pharmacies, and reimbursement agencies. Prescription information will be keyed in once (at the
time of prescribing) rather than three times. In addition, the need to manage paper based repeat
prescriptions within GP practices will be reduced and eventually eliminated.



                                                  14
Electronic Transmission of Prescriptions (ETP):
http://www.npfit.nhs.uk/programmes/etp/

VIII. DATA

A. STANDARDS

NHS data standards for England are nationally agreed by representatives of the DH, the NHS and
computer system suppliers. Patient based data standards are published in the NHS Data Dictionary
and Manual. The NHS Information Standards Board (ISB) provides an independent mechanism for
the approval of information standards in the NHS, assuring their integration and implementability.


    Data Standards: http://www.nhsia.nhs.uk/datastandards/pages/default.asp
    Information Standards Board: http://www.isb.nhs.uk/pages/default.asp


B. QUALITY, TRAINING AND EXTRACTION

i) Quality

Developments in data quality, accreditation and classification, and specifically the improvement of
the quality of morbidity coded clinical data, can be accessed via the link below:

Data Quality, Accreditation and Classification:
http://www.nhsia.nhs.uk/dataquality/pages/default.asp

ii) Training

PRIMIS (Primary Care Information Services) is a free training and support service to help GPs and
their staff make best use of clinical computer systems and boost data quality in primary care.
PRIMIS training and data analysis service is an integral component of the modernisation
programme in developing integrated primary and community EPR systems. It develops tools and
techniques to assist PCTs in comparative analysis, which will provide benchmarks as a basis for
tackling inequality in access. This facilitates the proactive management, comprehensive treatment
and monitoring of "at risk" patients.

PRIMIS provides training and assistance to information facilitators employed by PCTs, and
cascades knowledge and skills to GPs and practice staff. PCTs need to prepare a project plan and
employ a facilitator as a precursor to PRIMIS involvement. The complete process of achieving a
robust level of data quality can take as long as 2-3 years.


    PRIMIS: http://www.primis.nhs.uk/
    Disease Prevalence Figures: http://www.primis.nhs.uk/pages/Prevalence%20Figures.asp?om=m3


The new GMS contract ensures mechanisms are in place to manage and fund the training of
practice staff so that they may:

•      Use and manage their clinical and administrative information systems.
•      Understand clinical nomenclatures and classifications.
•      Ensure data quality.
•      Implement change management strategies to enable the move from paper to electronic
       records.
•      Risk manage and ensuring operational continuity.
•      Implement strategies to cope with the summarisation tasks associated with data flows.

iii) Extraction

Once data is of sufficient quality practices are encouraged to send anonymised morbidity data to
the PRIMIS Comparative Analysis Service using MIQUEST software. PRIMIS generated MIQUEST
query sets are distributed to facilitators to be run on clinical systems in local practices. MIQUEST is
a common query language for extracting and collating comparable clinically coded data from




                                                  15
clinical systems and is a mandatory element of all RFA accredited systems. However, MIQUEST is
not currently supported on all installed practice clinical systems

MIQUEST: http://www.nhsia.nhs.uk/nhais/pages/products/vaprod/miquest/

IX. IMPROVEMENTS

A recent article21 by a practising GP, published in the BMJ, suggested ten practical ways that
information technology in the NHS could be improved. These are listed below - many of them
covered by developmental initiatives already discussed in this document.

1) Send discharge summaries and clinical letters electronically to prevent the need to scan.
2) Allow the electronic transfer of records between practices. At the moment a record has to be
    printed off, sent and re-entered at other end.
3) Improve arrangements for sharing information and particularly the interaction between the
    hospital and GP record.
4) Make Lab-Links system work more efficiency as it is presently slow and unreliable.
5) Improve the speed and reliability of NHSnet.
6) Take the responsibility for IT maintenance away from GP practices. Store patient records on
    central servers so that the PCT is responsible for maintaining them.
7) More comparative data on practice activity should be available.
8) Start coding out-patient encounters.
9) More in-house training.
10) Allow hospital diagnostic codes to be sent to practices electronically.

X. GP COMPUTERISATION IN THE REST OF THE UK

The new GMS contract is a contract for all UK GPs. It will necessarily bring UK-wide alignment and
concurrency into many aspects of GP computerisation. Arrangements for the implementation of the
contract will be developed for Scotland, Wales, Northern Ireland and England in line with
developing policy. The historic and current national IM&T strategies for Northern Ireland, Scotland
and Wales are briefly covered below:

A. NORTHERN IRELAND

The Northern Ireland Health and Personal Social Services Department published its Information
and Communications Technology (ICT) Strategy Consultation22 in June 2002. It detailed the
current state of IT in family practitioner services and set out a strategy for future development;
identifying that ICT had little impact on direct care or on communicating care information between
primary care and the rest of the HPSS.

•   GPs should be encouraged to increase their use of ICT systems to record clinical data.
•   Developments in e-communication with primary care need greater conformity to national
    standards
•   There is already a high degree of standardisation in clinical systems as suppliers have to meet
    English NHS Requirements for Accreditation but these should be reviewed and formally
    adopted.
•   Legislation should be introduced to permit paperless records in GP practice so that those
    wishing to adopt EPR do not also have to maintain records on paper.

B. WALES

In 2003 the Welsh Assembly published a follow-up to Better Information, Better Health23 called
Informing Healthcare: transforming healthcare using information and IT24 which will constitute the
start of the overall Strategic Implementation Programme towards the ten year IM&T strategic
vision in Wales. The oversight of the Strategy will be undertaken by the Strategic Implementation
Programme Board supported by an Information Standards Development Group which may be
aligned to UK information standards bodies. Informing Healthcare is based upon progress in five
areas:

•   Care Process including integrated care pathways, e-booking systems, transmission of clinical
    communications, e-test orders and results, e-prescribing and dispensing.
•   Provision of access to new technology and skill development including the roll out of DAWN2
    (NHS Wales wide-area network) and staff training in health informatics.




                                                16
•         Patient and Public Empowerment including ready access to health records, transparency, and
          understanding.
•         Development of a Integrated Electronic Health Record in Wales which will be a single
          integrated record, structured around health/care status, that is accessible, holistic, protected,
          secure.
•         Better use of health information with: accountability for clinical data; access to local
          information support; and, management of routine information flows. As part of the data
          quality initiative, all general medical practices in Wales are currently being provided with a
          software tool called Clinical Audit. This tool can be used at the practice specifically to enable
          improvements in the quality of data held in the practice clinical information system.

Progress across these five areas can be monitored at:
http://www.wales.nhs.uk/sites3/home.cfm?OrgID=365

C. SCOTLAND

In 1998 the Scottish Office Department of Health published Taking Action 1998-200225 which set
out the NHS in Scotland’s vision for IM&T. The priorities for action were: supporting consistent
quality care; supporting seamless care between GPs and hospitals though electronic clinical
communication; linking the NHS in Scotland to a secure health service telecommunications; and
maintaining strong security and confidentiality standards.

In 2001 this document was followed by the publication of Strategy for Information 2001-200526
which is NHS Scotland’s National Strategic Programme for Information Management and
Technology. The three areas of the vision are: supporting direct patient care; providing
information; and developing the infrastructure. These will be realised by a number of National
Support and Development Programmes supporting: the development of the EPR and electronic
health record (EHR); confidentiality and privacy issues; Electronic Clinical Communications
Implementation (ECCI); telemedicine; Electronic Transmission of Prescriptions (ETP); smart cards;
unique patient identifiers; NHS 24; and, Scottish Care Information (SCI).

The situation in Scotland is unique in that one clinical system, the General Practice Administration
System for Scotland (GPASS) dominates the market with a user base of over 80% of surgeries. A
comparative assessment indicates that GPASS currently has the best appointments system in the
UK but it is clear that its clinical functionality needs to be improved if it to serve as the foundation
stone for the successful integration of Scottish EPRs27. With this in mind, GPASS is being
integrated with Scottish Care Information (SCI) products designed to flesh out the infrastructure
and develop the communications and interfaces which will deliver the wider vision28. SCI is a
national collaboration which is developing and making available Crown copyright IT systems and
standards to NHSScotland with particular emphasis on electronic clinical communication between
primary and secondary care, the EPR and, the EHR. These developments will be supported by the
Scottish Programme for Implementing Clinical Effectiveness (SPICE) which is an initiative designed
to promote consistent recording and use of clinical information across GP practices.

In 2004 NHS Scotland published the National eHealth/ IM&T Strategy 2004 - 200829 introducing a
vision based around the ubiquitous uptake of core national Integrated Care Record systems: SCI
Store and SCI Gateway. Care Records will be integrated at three key levels:

      •      Local GP/specialty electronic patient records, such as GP system or A&E system or a
             diabetic or cancer record, linked if appropriate to the Local Integrated Care Record.
      •      Local Integrated Care Record: NHS board-wide information system holding test results,
             clinical letters and summaries of care contributions. These may be assembled through
             speciality electronic records to give a clinician an up-to-date “view” of all information held
             about the patient in the SCI Store repository which the clinician is authorised to access.
      •      National Integrated Care Record: NHSScotland-wide based on the SCI Store information
             repository and holding copies of information from other national systems such as
             immunisation as well as summaries of information from the Local Integrated Care Record.


    Scottish Information Management in Primary Care: http://www.ceppc.org/scimp
    Scottish Care Information: http://www.show.scot.nhs.uk/sci/
    General Practice Administration System for Scotland: http://www.gpass.co.uk/




                                                      17
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   National Audit Office. Patient Choice at the Point of GP Referral. London: NAO; 2005.
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   Primary Care Information Modernisation Programme. Information and Information Systems for
Primary Care Organisations. London: Department of Health; 2001.
http://www.publications.doh.gov.uk/ipu/whatnew/itevent/pcoguide.pdf
21
   Majeed, A. Ten Ways to Improve Information Technology in the NHS. BMJ 2003; 326: 202-6.
http://bmj.com/cgi/reprint/326/7382/202.pdf
22
   Northern Ireland Health and Personal Social Services. Information and Communications
Technology Strategy Consultation. Belfast: DHSSPS; 2002.
http://www.dhsspsni.gov.uk/publications/2002/report_for_consultation.pdf
23
   NHS Wales. Better Information, Better Health: IM & T for Healthcare and Health Improvement in
Wales. A Strategic Framework 1998 to 2005. Cardiff: NHS Wales; 1998.
http://www.wales.gov.uk/subihealth/content/keypublications/englishimt_e.htm



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24
   NHS Wales. Informing Healthcare. Cardiff: NHS Wales; 2003.
http://www.wales.nhs.uk/sites3/documents/365/ihc-strategy-e.pdf
25
   Scottish Office Department of Health. Taking Action 1998-2002. Edinburgh: Scottish Office
Department of Health; 1998.
26
    NHSScotland National Strategic Programme for Information Management & Technology.
Strategy for Information 2001-2005. Edinburgh: NHSScotland; 2001.
http://www.show.scot.nhs.uk/imt/IMT2001Strategy.pdf
27
   NHS Scotland GPSS Review Group. Primary Care IM & T in Scotland: Promoting Progress,
Securing Success. Edinburgh: Information and Statistics Division; 2002.
http://www.show.scot.nhs.uk/gpassslg/GPASSReviewReport.pdf
28
   Pringle M. Bainbridge M. Horsfield P. Independent External Assessment of GPASS: Looking to
the Future of Health Informatics in Scotland. Edinburgh: Information and Statistics Division; 2002.
http://www.show.scot.nhs.uk/gpassslg/GPASSPringleReview.pdf
29
   NHS Scotland. National eHealth/ IM&T Strategy 2004 – 2008. Edinburgh: NHSScotland; 2004.
http://www.show.scot.nhs.uk/imt/


                                           **********


                                            CONTACT

            For further information please contact RCGP Information Services Section:

                              Royal College of General Practitioners
                                  Information Services Section
                                         14 Princes Gate
                                            Hyde Park
                                              London
                                             SW7 1PU
                                       Tel: 0207 581 3232
                                    E-mail: info@rcgp.org.uk


               The full series of Information Sheets may be downloaded at:
      http://www.rcgp.org.uk/rcgp/information/publications/information/infosheets_index.asp




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