Published: 13/06/2002, Volume II2, No.5809 Page 18

'Cradle to grave! Cradle to grave!' This the mantra chanted by the shamans of the electronic health record. Of all the elements of the NHS's IT strategy, this is the one that caught the imagination of politicians, the press and public.

The 'system' is supposed to record all aspects of primary, acute and community care, with the information then made available to support 24-hour care, health improvement programmes, clinical governance and epidemiological research.

A patient might be rushed to accident and emergency suffering a heart complaint. A condensed history or even complete set of records from the GP and acute units will be immediately available on screen.

This is all very attractive. But starting at a position where most GPs do not get electronic discharge summaries or send electronic referrals, it might seem a bit ambitious as a next step.

The big questions are how and what to deliver.While parts of Information for Health were very clearly defined, the EHR was a shimmering vision with no clear definition or plan. The work on acute electronic patient records was detailed and well thought through, no doubt aided by Frank Burns's experience as the chief executive of a large acute trust that had actually implemented an EPR.

Precise targets were set detailing the systems that trusts were expected to buy, in which order and by when. The result was a stampede of trusts to procure EPR systems.With EHR, on the other hand, the IT strategy outlines numerous possible approaches, including sending data between systems (datapush) and central repositories of information (data-pull). The strategy identifies goals and problems and talks vaguely about possible solutions, but there is no clear guidance because the whole concept is still in its infancy.

There has been a flurry of electronic record development and implementation programme demonstrator activity where EHR projects have been centrally funded to show the way. There have been investments in 19 projects to date, seven of which are near to completion, and the NHS Information Authority is currently conducting detailed reviews of these projects.

Although some of these pilots are expected to shine, most are small-scale and show only a small part of the EHR vision. Funding for further pilots was squashed in recent IT policy announcements.

The Department of Health has launched a parallel EHR initiative, the LifeHouse project in west London.Here the idea is to connect the islands of patient information, with the emphasis on a practical way to make named records available for immediate care and anonymous records available for research and analysis.

The interesting thing is that it intends to develop a solution without having specific answers in mind at the start. It seems to be a true research and development project. This approach is required if the principles of EHR are to be properly developed.

While it is generally agreed that EHR is a good thing, it will take many years to develop and understand the model for a successful implementation. In the meantime, there is still an urgent need for better communication between healthcare professionals.

For EHR to succeed, patient data must be available on the distributed systems at the various healthcare providers.This means, for example, that primary care trusts must upgrade their GP systems to support their new structures and that acute trusts need to continue their march towards EPR level 3 and beyond.

The strategy's tremendous forward momentum must not be halted by planning blight.

We must also get to grips with messaging between providers and systems.Ambitious plans for airline-style booking are all very well, but we still do not have a national message structure for sending a referral to a hospital or clinical letters to clinicians or discharge information to GPs.

We must also address security and confidentiality. It is neither sufficient nor practical to obtain patient consent for the general or specific distribution of clinical information.We need to decide who should see what and when.

My advice is make haste slowly, and, at the risk of torturing a metaphor, paddle your own canoe. EHR will be easier if the shamans stop chanting 'cradle to grave'until the architects have checked the scheme is built on solid foundations.

Markus Bolton is chief executive of a healthcare computer systems supplier.