Published: 17/03/2005, Volume II5, No. 5947 Page 12 13 14
When information matters this much, roles change as fast as the technology. Steve Mathieson and Nick Edwards talk to the people who personify a revolution
The regional leader
Richard Popplewell is an embodiment of the cliché that technology needs board-level leadership. The Stockport primary care trust chief executive is also chair of Greater Manchester information management and technology programme board, which represents the area's 27 trusts.
He took the job of IM&T chair in autumn 2003. 'The board has got the role of co-ordinating the implementation of the national programme for IT, and has a relationship with the North West and West Midlands cluster, ' he says.
The board meets regularly with CSC, the local service provider: 'We have a monthly cycle of meetings, to try to see where we are with the implementation. At the moment much of that is still in the planning stage.' The current situation generates a certain amount of impatience.
'Managers and politicians alike have sold the potential of these systems, and then can't deliver it the day after, ' he says.
Locally, the early work includes a patient administration system in Tameside and Glossop and Stockport PCTs, for which training is now taking place. Greater Manchester strategic health authority area has been split into four sectors (of which Tameside and Stockport is one) for implementation: 'It is how to split this enormous national project, split nationally into five clusters, clusters split into SHAs, and in Greater Manchester, into sectors, ' he says.
'I've got a background in IT, ' explains Mr Popplewell. This comes primarily from information analysis:
his degree was in statistics and operational research. 'In the olden days, I was a regional statistician. I come from the analytical sciences, rather than the wires and boxes.' This is not Mr Popplewell's first job representing Manchester on IT.
'I used to represent the Greater Manchester community on the chief executives' information forum, and by chance and good design, I am also vice-chair of the NHS Information Standards Board, ' he says. 'I was pleased, and keen, to be the link and the lead PCT chief executive on the Greater Manchester IM&T board.
'The major change for me is the move from individual organisations pursuing their individual needs and requirements, to a national programme with ruthless standardisation of approach. It means there has to be some compromise by individual organisations about acceptability, flexibility, suitability, but the benefit is from working across the country.
'Very significant initial resources have been pumped in. Locally, we would never have found the collective ability and will to decide to spend all this money on IT together on standardised systems. It had to come from the top.' He acknowledges that the topdown approach has caused some disquiet. 'The discomfort you hear now around the national programme is about people coming from very legitimate different perspectives: those that are well advanced feel a bit frustrated, those that have nothing will not get everything tomorrow. We haven't got a level playing field to start, and to get us up to that, There is bound to be some disquiet.' Mr Popplewell works with Greater Manchester SHA chief information officer Roger Dewhurst.
'Roger and his team manage most of the business to the board. My role is to bring a general management perspective, interest and commitment to things.' He says it is useful to have a background in technology: 'But given that IM&T is increasingly on everyone's desk, It is a much less rare knowledge base than it was.
'It is only of value if we implement a service redesign and modernisation programme alongside it, ' he says of the national IT programme. 'One of the challenges across the country is to put in IT as a necessary tool of service modernisation, rather than being an end in itself.' For Greater Manchester, this has meant pushing the programme to cover tier two: care offered as an alternative, or an intermediate stage, to a GP referring someone to a hospital consultant.
'We are extending that across Greater Manchester in orthopaedics and other services at tier two. The national programme didn't initially - but now does - accept there was a stage in the patient pathway between a GP and an outpatient appointment in a hospital.
The programme is redesigning its choose and book software to allow [tier two] assessment processes. That change and improvement will be continuous, ' he says.
But there are also more basic elements of the programme to worry about. 'One of our major challenges is the capacity of the N3 broadband system. Until it is everywhere and reliable and fast, then the potential of everybody having screens in front of them will not be delivered.' Mr Popplewell says that changing IT has changed his job in a rather more down-to-earth way as well.
'The paper in-tray is much reduced but the electronic in-tray feels larger than even the paper in-tray was before. Because It is so easy to send everything to everybody, the general manager's in-tray gets an awful lot of information in it.'
The head of information
Sandwell and West Birmingham Hospitals trust head of information Helen Nicholls joined Birmingham's City Hospital as an information assistant in 1990, after a year in the private sector.
'There was a lot more working on paper, so you would print reports out from the patient administration system and add them up with your calculator, ' she says of the early days at the hospital.
'These days you can report straight off the patient information system.' As a result, managers can now be told what's going on in real time, 'if they want to know what's going on in accident and emergency this minute, not last night or a week ago'.
The pace has also changed in communicating the results. 'People would send you a letter requesting information, whereas now It is all email, ' says Ms Nicholls.
This made one aspect of life easier: 'For a long time, We have been submitting the waiting-time reports to GPs. We posted them out, which took hours stuffing envelopes. These days, It is on the website, ' she said, and will soon appear on the choose and book system.
Another difference comes in the hardware used. In the early 1990s, staff shared one computer between two and juggled floppy disks; everyone now has their own computer and all data is held on a central database. The central hardware is much smaller: 'The City computer room now has lots of space, whereas it had this enormous beast which the patient administration system used to run on, ' says Ms Nicholls.
There are more staff now. In the early 1990s, just three people were employed in this area by City Hospital and the district health authority, whereas Ms Nicholls now manages a comparable department of 10 people. Although three come from Sandwell hospital, there are other staff at primary care trusts, doing work which was once done by the district health authority.
One reason for the expansion is the increasing frequency of data demands from the Department of Health. When she started, 'we filled in annual Korner returns, whereas now We are on daily submissions through websites, ' says Ms Nicholls, referring to information like that relating to winter pressures. Other returns have to be completed weekly.
Furthermore, there is much more interest in the data generated, as a result of widely publicised targets: 'I think That is one reason why these departments have grown so much, ' says Ms Nicholls.
Things will soon change again, as a result of the national programme's national reporting database, the Secondary Uses Service. Much of the trust's data will be held by the programme, rather than the trust's own systems: 'We do an awful lot of data quality reporting at the moment, flagging up data where it doesn't seem to be right, ' says Ms Nicholls. 'It will be quite different for us [with the programme], as we are used to querying the live system.
'With the new one, it will be very restricted - the whole of the SHA will be going onto one system. At the moment, It is our data and we control it, but the restrictions will get tighter and tighter as to what we can do, ' she says.
This could cause difficulties when managers see general reports, such as on the performance of clinicians, and want to know more: 'We'll be asked to give the data behind it.
Every trust tries to get behind the data.' Overall, Ms Nicholls believes that the increasing amounts of data usage are worthwhile. 'I definitely think targets work, otherwise there is a risk that things just chug along and nothing changes.' Take the fourhour A&E target: 'A&E departments are different places because people do not wait around overnight in corridors any more, ' she says.
THE CLINICAL CODERS BACK-OFFICE TO FRONT
'They used to have a name - the cardigan girls. That gives you an idea of how it was viewed, a back-office function that wasn't much of a career.
That is changed now.' University Hospital Birmingham foundation trust head of informatics Irene Darlaston is describing the radical development in clinical coding over the past five years.
In a sense the journey began four years ago when the trust's information governance team did its first trust-wide review of clinical data, with each consultant being given their own recent information to review. This was driven by plans to publish information on clinician mortality rates - getting accurate information on case-mix was therefore essential.
Ms Darlaston says: 'You can imagine what some of the responses were - first, the data was rubbish, second, they hadn't got time to check it. But a number of clinicians started engaging and we learned lessons on both sides. It was a big cultural change.'
Divide and rule Last month the trust restructured its clinical coding staff to reflect its four clinical divisions. Each division will now have its own coding team led by a senior coder, with all four divisional teams reporting to clinical coding coordinator Sian Litowski. Apart from the senior coder, all other staff will rotate between divisions every six months to ensure a spread of knowledge.
Among the new system's benefits, it will ensure that coders build a specialised knowledge of a clinical area, a big help in establishing good relationships with clinicians. It also creates a more obvious career path for coders.
In the run-up to the new structure, Ms Darlaston and Ms Litowski have organised meetings with clinical directors and managers to tell them how coding impacts on their jobs.
Ms Darlaston says: 'They have been very positive meetings.
When clinicians realise that often information is wrong because of the data coders are given, they are willing to give better information.
For instance, many junior doctors put information down without indicating whether a stroke is part of a patient's case history or is new - that changes data if you do not audit that.'
One of the major levers is the fact that completion of the Korner returns is now part of each consultant contract.
As Ms Darlaston says: 'When It is about someone's payment and revalidation, It is very personal to them rather than just a corporate service.' The contract specifies that each consultant must achieve 90 per cent compliance and this will be audited regularly. This will be a major change given that current average compliance is probably no more than 25 per cent. 'Of those some consultants will already be compliant, while others will not have filled in a Korner return in their life.' Ms Litowski says: 'We are very keen to make this new structure work for us and let us work differently. It will give us more responsibility within a division and allow us to gain specialist knowledge and create closer links with clinical staff.' 'Skills are not just technical, It is also about communicating with people. It is about knowing people's jobs and knowing what they need from information.'
Interactivity Ms Darlaston says of closer interaction with doctors: 'When you speak to clinical coders about the new structure, It is one of the areas of the jobs that they often do not think they will like.
They can think that clinicians will be intimidating and unhelpful. But the coders are coming out of meetings feeling very comfortable and confident because they have a basis in knowledge of the subject.'