The latest IT strategy has been consolidated in the NHS plan, as Jane Dudman reports

Up and down the country, NHS organisations have put in place their local implementation strategies to meet the demands of the government's Information for Health national framework for information management. Now they are grappling with the challenge of getting systems in place to make the whole thing work.

A key plank in implementing Information for Health and the more wide-ranging NHS plan is the need to automate patient records. The idea of the electronic health record and electronic patient record is hardly new: since the dawn of computing, the health service has struggled to face the challenge of how to move from inefficient paper note-taking to an online world.

So far, though, answers have tended to be piecemeal.

With Information for Health and the NHS plan, the service has a framework within which to work and, in particular, to grapple with the complexities of how lifelong online patient records should be structured. Integrating EPRs with a central patient EHR presents major technical, security and organisational challenges for the NHS. Interfacing information from individual patient records for specific episodes and events held by disparate parts of the service - such as GPs or consultants - with a central patient record is a particular problem.

The NHS Information Authority has set up the electronic record development and implementation programme to look at this whole area. Initially, four pan-community pilot sites, in Cornwall, Tees, South Staffordshire and Durham, were given£2.4m to run two-year EHR projects. In June this was followed by a£5.8m scheme, involving 13 EPR pilot projects.

They cover various aspects of electronic recordkeeping, including streamlining patient records in priority areas such as cancer and coronary heart disease; developing integrated care pathways; and linking health with social care as well as NHS Direct, walk-in centres and primary care.

The initial batch reports from the EPR demonstrator sites are now being evaluated by the Information Authority. The demonstrator sites will provide valuable lessons for implementing electronic records, but they are only one part of a wide range of activity right across the service on implementing and assessing the issues involved in this area. 'The reality is that it is not just the demonstrator sites that are making progress, ' comments Steve Graham, operations director at software firm iSoft, which supplies an integrated electronic record package to several healthcare organisations.

'Obviously, the funding is a help, and the pilot projects will give visibility and credibility to what is being done, but we have many other customers in the health service achieving EPR objectives.'

Mr Graham adds that because technology is changing so quickly, running a two-year pilot scheme is not necessarily the quickest or most effective means to evaluate systems in this area.

Change is happening fast, he says, and many of the practical obstacles that have previously held up progress are now being removed one by one.

Closer working between primary and secondary care bodies, as well as between different government organisations involved in health decisions, has been a major step forward, as has the publication of a coherent national plan in this area.

'Clear guidance from the centre is important in all kinds of areas, such as how booked admissions should be handled, ' says Mr Graham. 'These issues are now being worked out, and they have been kick-started by the Information for Health plan.'

While many in the health community have welcomed the NHS plan and the pilot projects, some are worried that setting explicit targets may encourage health bodies to do only the minimum involved in reaching the targets set in the plan, rather than thinking more long-term.

Sean Brennan, head of healthcare strategy at Northgate Information Solutions (formerly MDIS), says some organisations could fail to reap the benefits from implementing a complete electronic records strategy.

Before joining Northgate, Mr Brennan worked for the NHS Executive and helped develop the six-level model for EPRs on which the NHS modernisation plan is based (see box).

As part of the plan, trusts are being told to implement at least EPR level 3 by 2005. 'While the Information for Health target is a good idea, there is a real danger of people seeing it as a specification, ' says Mr Brennan.

'In fact, the real clinical benefits will come from implementing the levels beyond that, in order to provide clinical-based support and rules-based prescribing.'

There is also concern at the sheer level of demand for new systems, as health bodies begin to implement their local strategies.

'The challenge from the supplier perspective is getting through the procurement, because every trust has to do this, and every one has to develop its own local implementation of the Information for Health strategy, ' Mr Brennan points out. 'There will be an incredible amount of activity for suppliers as those tenders then go out.'

Other firms feel hold-ups could be on the NHS side, rather than on the suppliers' ability to respond. Mike Singer, managing director of Elan Technologies, which specialises in healthcare systems, says that while the aims of the NHS plan are excellent, getting there will be more difficult, partly because of that long-standing NHS bugbear, red tape. Mr Singer says the health service, despite valiant attempts in many areas, has still failed to streamline its procurement processes - they are slow, while technology has moved on.

Overall, like other suppliers, Elan welcomes the NHS targets for electronic records and, like Mr Brennan, Mr Singer believes the real benefits of the move will come as the higher levels of the six-layer EPR model are implemented, particularly for guidance on prescribing.

'The benefit is that you get consistent healthcare, the clinicians are given a way to treat patients in line with proven best practice and there is a clear audit trail in the system, ' says Mr Singer.

Most health bodies, however, are some way from achieving even level 3 of the EPR model, let alone getting to level 6. Previous lack of investment in network infrastructures, on which efficient EPRs depend, is hampering many sites. Solihull Healthcare trust, for example, has identified six main barriers to progress with EPR in its community and mental health services. These are:

Confidentiality and security concerns.

Lack of funding.

Lack of information management and technology support staff.

Need for training and education.

Not all sites are connected to the network.

Need to upgrade some users from dumb terminals to PCs.

So far, Solihull has achieved levels 1 and 2 of the EPR model and is building on this to move towards level 3. On the acute side progress has been slower. Heartlands & Solihull Hospitals trust has achieved only level 1, although it has rolled out an in-house results service as part of its level 3 implementation. While progress has been made in many areas, it can be difficult for trusts like this, particularly given the present shortage in IT and project management skills, to move forward as fast as they would like.

Despite this, many NHS organisations are optimistic - or realistic about the fact that they cannot afford to be left behind. Oxfordshire's strategy, for instance, says it is 'inconceivable' that in five years' time the majority of clinical processes in the county should be still dependent on paper-based manual records and communications. But it is clear that with so many organisations at very different stages of implementing systems-based records, it is going to be difficult to co-ordinate these activities.

Oxford Radcliffe Hospital trust will spend the next two years expanding its workstation and network infrastructure and making the most of its existing systems, particularly its clinical intranet. More long-term, the trust wants to replace its existing pathology and patient administration systems, as well as develop order communications and electronic prescribing. Its existing PAS has already been merged across all trust sites, as have its radiology and finance systems, while lab information is provided via the existing clinical intranet. Overall, the trust reckons it is progressing well in meeting levels 1 and 2 of the EPR model. But at level 3, while results reporting is in place, there is no provision for electronic ordering and only patchy provision of multi-professional care pathways so far in its renal and maternity departments.

Reaching level 3 of the NHS plan and beyond for EPRs and integration of systems is taking a lot of time and effort across many organisations.

While no one doubts the fact that this is the way the NHS has to move, getting there is going to be a long slog for some.

Going live: Cornwall and Isles of Scilly

ERDIP project leads the way The Cornwall and Isles of Scilly project is one of two national demonstrator sites for developing electronic health records. Cornwall was chosen because its health community has worked together in creating a cultural, technical and data infrastructure, writes Andrew Forrest.

Other projects under way will also help deliver a new generation of integrated patient care systems. For example, Cornwall has health action zone status, and is a national mobile workshop site for the clinical workstation. Its telemedicine implementation was overall winner in the 1999 National IT Effectiveness Awards. Cornwall HealthNet is a voice and data network to all healthcare sites and the gateway to NHSnet. Cornwall has successfully implemented an innovative integrated data architecture, and has a single health informatics organisation.

The Cornwall project complements the other ERDIP sites, aiming to deliver local benefits and act as a practical model for national development. Its objectives are:

To create an integrated patient record between primary and secondary care, providing a 24-hour view for the out-of-hours GP and mental health service.

To report on the development processes and lessons learned. This includes the radical care process change in introducing telemedicine; the pitfalls of integrating three information departments; and the challenge of creating a truly community-wide integrated data architecture.

To develop and demonstrate the value of the electronic record for mental health, cardiac care, diabetic care and therapies across the health community. Cornwall will also demonstrate support for implementing the cardiac and mental health national service frameworks.

All of the objectives have been put into a rigid project-management structure to ensure delivery on schedule. The first reports - to be published and presented in a series of workshops to be arranged by the national ERDIP team - describe the framework put in place to start to develop community-wide electronic records. They are:

Information services integration evaluation, which looks at the approach to merging three information departments into one and the issues raised, discussing planning and practical problems. The benefits of a single organisation are highlighted in the context of delivering major projects and supporting new organisations such as primary care trusts.

Creation of the Cornwall HealthNet, which describes the philosophy and benefits of implementing a 'natural community' solution to the GPNet project.

Creating a Single Population Index, which describes the processes and benefits of moving from multiple patient indices to a single index. The paper looks at the uses of the NHS number in integrating patient information.

Creating the integration architecture, which is a visionary data structure designed for integrating patient care information. This is the framework for gradually moving away from legacy computer systems to new clinical and support systems in a manageable way. The architecture is working, linking laboratory systems, core patient information and new clinical care modules.

The telemedicine evaluation paper discusses the use of technology in support of changing clinical processes in minor-injury units, accident and emergency, dermatology and GP surgeries. The paper highlights clinical, technical and process issues that need to be considered and resolved to make telemedicine a success.

The system developments have reached the stage where project teams are established and are busy specifying requirements. Clinicians' input into the process is crucial, and more than 100 have directly contributed as team members. Specifying requirements from scratch puts the ownership where it belongs, with the clinical staff. The teams identify risks and issues and create task scenarios. Task scenarios mimic real-patient problems, and test both the requirements produced by the team and the computer system's capabilities.

The requirements documentation suite will be available for other NHS users as a specification or as a comparison against local requirements. The documents will be used to develop new, or enhance existing, software. All modules are then fully integrated with each other and with the core patient record. This means in practice that information is entered only once but can be available anywhere appropriate in the Cornwall health community - for example, the patient's date of birth and medication from both primary and secondary care.

The integration architecture is up and running. The core of the integrated care system is also working. The development work is on schedule and will be demonstrated next year. Much of the documentation will be published later this year.