A Highlands trust that has to communicate with GPs in far-flung areas is using an intranet-based system to send test results electronically. Peter Mitchell explains how it works

Many acute trusts are trying to achieve speedy access to lab results for their own clinicians and ward staff as well as local GPs. The need to deliver results electronically is particularly pressing for Highland Acute Hospitals trust, in Inverness, which serves a catchment area of 10,000 square miles across the Scottish Highlands.

The trust's biggest hospital, Raigmore, first started thinking about electronic results transmission when a survey found that surface mail containing discharge letters or results could take as long as six days to reach GPs in remote communities 150 miles away in the west of Scotland.

The trust initially tackled this problem by establishing a rudimentary e-mail system with these remote practices to handle discharge letters and results. This solved the immediate headache but, not surprisingly, left staff working at the trust itself feeling at a disadvantage: GPs on the other side of the country could get results instantly, while in- house staff had to wait for the print-out to arrive through the internal mail - which only came three times a day.

So the trust tried to extend the e-mail system within Raigmore. But with several different internal systems in use, it wouldn't work satisfactorily.

The need to find a more effective solution came to a head in spring 1997, when Raigmore held a workshop involving 40 staff from across the healthcare community in the Highlands to set priorities for its new information management and technology strategy. Attendees regarded results reporting as second only in importance to tackling the year 2000 bug. With this backing, the trust once more looked at the available systems.

It identified an approach which was finding acceptance in several NHS organisations in Scotland and began trials in half a dozen wards in autumn 1997. According to Mike Lister, Highland Acute Trust's head of IM&T, the product worked well and was accepted to a reasonable degree by its users.

But the trust had some reservations. 'At that time, we were moving into web-based technologies for other aspects of our infrastructure, but this product was based around a traditional client-server architecture,' he says.

'We see the intranet becoming the common desktop for all staff and their access route into all the trust's systems. So if we had the opportunity to provide results reporting through the intranet, we felt we should do that.'

Mr Lister continued to look for a web-based results reporting solution even as he was evaluating the client-server system.

Then he saw the work being carried out with Microscript's software at Kettering General Hospital trust. He decided to test a system developed using these tools in the same areas and environment as the client-server- based system, to allow a direct comparison to be made.

His evaluation was based on:

the ability to link to other systems at the trust, particularly to its MDIS Homer patient administration system;

the ability to identify and list all patients belonging to a particular consultant;

ease of use and low cost of access for GPs;

strong confidentiality and security measures;

colour-coding of abnormal results;

identifying trends in results;

an acceptable cost.

Both solutions met all the criteria. Mr Lister sent an evaluation form to the 200-plus users who had piloted the two systems.

Respondents overwhelmingly preferred the Microscript-based system, because of the familiar 'look and feel' of its web-style front-end. Mr Lister also considered it to be better in terms of future linkage, identifying trends and cost.

Raigmore has installed the system on relatively new hospital-wide intranet infrastructure rolled out in autumn 1997. It uses 'thin client' technology and a range of Microsoft products including SQL Server, Exchange and Windows/NT.

Establishing this infrastructure was prompted by a business strategy review in 1996, which identified lack of communication as the most significant failing in the trust, says Mr Lister.

Once the intranet was in place, the first step in establishing the results reporting system involved using Microscript to extract results from the print-to-file output from the haematology and biochemistry modules of the trust's Medipath laboratory system. These are then converted into the appropriate format before being stored in a database on a password- protected area of the intranet.

The software then generates Active Server pages, which display the information to users via a web browser on a thin-client machine. Client browsers run in 'kiosk' mode. This means that when a user has disconnected from the machine, all the information is flushed from the machine and the next user cannot log into any pages that have previously been viewed.

Storing the results data in an intermediate database allows many more users to access results than could be sustained if they were linking directly into the source applications.

Raigmore's results now reach ward staff in less than 25 minutes after completion of the test.

The details of the individual laboratory systems are hidden from ward users, so that they only have to learn one interface to access a wide range of data. The trust has since linked its patient administration system to the results reporting application, to allow staff to search for patients and results more easily. Rather than using screen scraping - which would have involved pulling data from many different screens - the data is pulled into the Microscript software through a batch file generated from the PAS every 10 minutes.

This file contains details on patients and their location. Lab results for each patient are appended to these records. Using hyperlinks, staff are now able to jump directly from a list of patients on their ward (or, in the case of consultants, under their care) to the results for a particular patient.

And because the data on patients drawn from the PAS is held in an intermediate database, Raigmore is using it to populate dynamic screens showing current bed occupancy.

This is helping clinicians and managers to identify pressure points within the hospital and respond to the issues they raise.

This in turn has identified the need for a user-friendly front-end to the PAS admission, discharge and transfer screens, to encourage nurses to record patient movements as quickly as possible. So Mr Lister's team has developed a web-based front-end to the PAS, which is now being evaluated.

They have also developed interfaces to the MDIS radiology system, and scanned images of vascular profiles - making these images and reports available through the intranet.

Both implementation and ongoing operating costs are relatively low because the client application needs very little support while the data can be managed and secured centrally.

The benefits are also clear for laboratory staff: the system reduces significantly the amount of time laboratory staff spend answering telephone queries, allowing them to concentrate on their core activities.

'A small sampling exercise showed that telephone calls into the labs fell from 52 to 14 over a two-day period,' says Mr Lister.

Improved reporting should also reduce the level of out-of-hours service needed to deliver the same benefits to patients and clinical staff, while duplicated tests should be eliminated.

The system started on seven pilot wards and has now been extended to over 60 PCs throughout Raigmore. The plan is to extend it to other hospitals in the trust at Wick and Fort William.

Beyond that, says Mr Lister, the trust intends to offer the system to GPs who can access the intranet via NHSnet.

First the trust has to sort out its NHSnet link and prove compliance with the code of connection.

Future plans include setting up interfaces to the remaining laboratory disciplines, and extending the reporting mechanism to electrocardiograms and clinical correspondence such as discharge letters.

'We are effectively building up an electronic patient record using legacy data,' explains Mr Lister.

'We are taking all the different kinds of information which are currently available electronically and holding them on a single logical database as if they were all results.'

The trust is also considering using Microscript to develop an order communication system with the same look and feel as the results reporting system. The same browser could then be used to order tests, x-rays, and prescription drugs.

Highland Acute trust and Microscript's Scottish re-seller, Channel One, are also now working on a project to access community health index data. This is funded by the NHS Management Executive in Scotland and run in conjunction with Highland health board and a neighbouring primary care trust.

It aims to allow staff to use demographic data to search not only their local PAS but also an intermediate database holding community health index data on patients in the region and, ultimately, the mainframe holding the entire set of community health index records for Scotland.

This will help NHS organisations in Scotland to make use of the community health index number as a unique patient identifier in their own records and to share information on patients between organisations more easily. Highland has now put a detailed proposal to the Management Executive to finish the project.

On top of that, Raigmore is working with Highland health board to investigate whether the same software can be used by GPs to book outpatient appointments while patients are still with them in the surgery.

The service is currently being piloted by three specialties at Raigmore and at two local GP surgeries.

Early results of the evaluation look good: patients of the participating practices can be provided with the date and time of their routine outpatient appointment before leaving the GP's surgery.