Published: 26/09/2002, Volume II2, No. 5824 Page 12 13 14

Confidence is high in the development of web-based electronic patient records, but compatibility issues remain. Jane Dudman reports on the progress of several systems

Web-based systems are springing up like mushrooms across the health service. But will they, as some people claim, smooth the bumpy road towards electronic patient records?

Yes, say supporters. But it is, in some cases, a qualified yes. As with anything that combines technology and the health service, nothing is ever as simple as it seems.

The foundation for most web-based developments in the health service is XML. This is the technology that 'marks up' documents for use on the internet and forms part of the government's e-government interoperability framework (e-Gif ) standard for government data transfer.

1For a number of reasons, XML has been embraced wholeheartedly by the NHS in its drive to develop EPRs. In particular, it enables systems to be built that are easy for clinicians to access.

'The challenge is to present information to clinicians that conceptually resembles a physical set of case notes, and XML is an attractive way to do this, ' says Dr Chris Tackaberry, head of clinical applications at supplier iSOFT, which is developing a number of XML-based systems, including one at Sandwell and West Birmingham Hospitals trust (see box 1).

XML works as an information transport layer between systems in which data is held (which are often old, stand-alone systems that work fine but would cost a lot to redevelop) and a web-based front end that can be easily accessed via an internet browser.

'Once you have built the machinery, you can haul in data from different systems, so ultimately it all gets converted into XML files, ' says Dr Tackaberry.

Some in the NHS are very confident that most of the technical issues around EPRs have been cracked and the remaining obstacles are cultural.

Others are less convinced. 'All the people working with XML in the health service at the moment are pioneers, and everyone does things slightly differently, ' says Andy Hadley, IT manager at Poole Hospital trust, an early adopter of XML, which is running a system from software company Graphnet to hold 15 million records.

Mr Hadley believes a national standard will be important to avoid future problems. 'Within our own system, It is fine, but when you need to pass information to another hospital or back to primary care then you can get problems, ' he says.

Tony Sharer, operations director of Graphnet, says there is bound to be some degree of duplication of effort as so many different NHS organisations and suppliers focus on XML-based development. But he believes this will inevitably shake out and doubts if work on national standards will be ready in time.

'There should be standards, but if they are devised in the usual way, we will get them too late, ' he says.

'There is a place for standards, but they need to be developed jointly with the people at the coal face, not in an ivory tower. In medicine, what is being used today will not be the same in a year's time or two years' time, so the health service needs a flexible way to record its information.'

Graphnet believes the way to meet the requirements laid down, for example, in last year's guidance from the British Medical Association on remotely held records, is to build an electronic record from 'read only' XML documents held in central repositories, rather than by creating 'virtual' records using web services to pull together information as it is needed.

'These are legal documents and you have to build in an audit trail and be able to see when changes have been made, ' points out Mr Sharer, who adds that the 'virtual' approach demands infrastructure that is not yet widely available across the NHS.

Much of the appeal of XML is that it sits on top of existing systems and provides a flexible way to continue developing as information needs change.

This means projects can be built as they are needed, at a fraction of the cost of building a major new system.

In trusts such as Wrightington, Wigan and Leigh, Continued from page 13 where money is tight, this is an important consideration (see box 4).

Philip Firth, information management and technology strategy implementation manager at Wrightington, Wigan and Leigh trust, has previously tried the 'big bang' approach to building an EPR.He is now convinced that the 'best-of-breed' path it is taking is the best, indeed the only, way forward.

'My previous experience is that you can take massive strides forward in integrating systems, but when you get down to the level of integrating data from an individual clinic it falls apart, because there just is not enough flexibility, 'Mr Firth says.

Dr Ravi Bickram, head of technical marketing at supplier ComMedica, says NHS developers need to distinguish between suppliers with web-based systems and those that are merely web enhanced.

The difference is between architecture that is fully based on internet technologies and configured to be used via any browser, and systems where web access has been added on.

'XML is ideal for connecting between different systems, ' he says. 'It is like a handshake - it understands which fingers are which.'

Dr Bickram says web-based access to clinical systems is proving hugely successful.

Not all web-based systems are based on XML.

There are other ways to deliver information from back-end systems into a browser front end.One organisation that has adopted a different route to this concept is the United Bristol Healthcare trust, which is using a well-established technology, terminal emulation, to deliver data to clinicians.

'Five years ago, we needed to develop a way to deliver information to clinicians via our intranet, ' explains Arthur Matthews, head of information systems development at UBHT.

'We were also beginning a programme to prepare for EPRs and while we wait for that, the change process in our trust is huge.'

The answer to this two-fold need to get information out to clinicians, while moving towards an EPR, has been to provide access to medical records via an intranet-based clinical portal using software from US connectivity company WRQ.

Its Reflection and Reflection for the Web software helps link desktop PCs to the trust's main data servers and provide a flow of up-to-date information and almost real-time reports.

One of the main consequences has been a realisation that, across the trust, the quality of data held in many systems is not as good as it should be.

This, Mr Matthews says, is a vital lesson in the runup to implementing an EPR.

'The preparation for EPR extends far beyond technology, ' he says. 'As more and more PCs go into wards and people access this information, they can see just how bad the statistics are.'

Information on bed states, for instance, proved to be widely inaccurate: 'Data quality has now improved dramatically.'

He remains sceptical, however, about the ultimate goal. 'EPRs are being sold as a panacea and that is frightening, ' he comments.

The real problem, he believes, remains the previous level of underfunding for NHS IT, which has left many organisations with ageing systems.

'XML can do nothing about that, ' he points out.

'EPRs will cost a huge amount of money and whatever we buy will not produce what's been promised.'

Box 1: Birmingham City Hospital, Birmingham Simplicity is the key to the development of the web-based patient record system in use at Birmingham City Hospital, part of Sandwell and West Birmingham Hospitals trust.

Initially developed internally as a simple homepage, with a number of reports for clinicians doing ward rounds, the system has now been developed further by supplier iSOFT, which is implementing an EPR for the trust.

It contains a portal to useful reports, trust information such as the junior doctors'handbook and external internet sources.Users can link from all reports to the web-based EPR by entering a patient number.The iSOFT development, known as iSOFT Clinical Centre is preferred by clinicians because it is easier to use.

'There is a lot of very valuable clinical information held in very old clinical databases, 'explains Dr Chris Tackaberry, head of clinical applications at iSOFT.'XML is the middleware that hauls out data from these different systems.'

Dr Tackaberry says the team at Birmingham and his own staff have learned a number of lessons from this development, including separating out when a web-based system is more appropriate.Not surprisingly, perhaps, it has emerged that where professionals have more complex information needs, it is harder to provide that information via a web-based system and this is an area where more development work is needed.

Box 2: Victoria Hospital, Blackpool The web-based EPR used in the occupational therapy department of Blackpool's Victoria Hospital, part of Lancashire Care trust, has one major difference from many other such systems: it has grown out of a system entirely written by one of the occupational therapists.

The initial system was written by senior occupational therapist Chris Anderton using Microsoft's Access database.As a result, it has developed from the needs of the OT department, instead of imposing its requirements on them.

'A lot of people developing EPRs in the NHS end up fitting their clinical practice into the requirements of the system, to some degree, 'Mr Anderton says.'My system provided all the information needed and we had complete control over it.'

That initial system has now been developed further, at the cost of between£10,000 and£12,000, by web specialist Odyssey Interactive, to enable it to interface more easily with other systems and to provide a web-based approach, rather than the internal, networked system originally developed.

The result has kept the core functionality of the initial system, but provided much greater potential, says Mr Anderton.

'We haven't yet got electronic referrals, but that will be the next step, 'he adds.'And because the system is web-based, the opportunities for access to the data are unlimited, which is wonderful. I can log on from home, or from a patient's home, and get into the system via NHSnet.'

At the moment, the system is being used only for occupational therapy, but the trust is looking at using it as a core platform for care programmes across the whole of its mental health provision.

Box 3: Princess Margaret Hospital, Windsor The impetus for developing web-based access to patient records at the private Princess Margaret Hospital in Windsor has nothing to do with government edicts or standards setting.

Instead, the web-based Patient Record Library System (PiRiLiS) is designed to respond to a need for clinicians to access patient data wherever they are, when it is convenient for them.

Rosie Faunch, executive director, says that most of the PMH consultants live and work anything up to 15 miles from the hospital and want access to test results from wherever they are.'The consultants can keep in touch while off site and can respond to changes as and when required, ' she says.

The system, built by ComMedica, uses XML as the standard for data exchange when it pulls data from pathology and radiology systems at the hospital.Once that data is in PiRiLiS, consultants can access it securely and remotely, making it easier and more convenient for them to check test results.

Consultant orthopaedic surgeon Andy Unwin, who uses the PiRiLiS system, says it has a good deal of potential, beyond simply providing pathology and radiology results. It is, he says, a 'first step' towards complete electronic patient records.

Box 4: Wrightington, Wigan and Leigh trust 'In a trust like Wigan, where There is not much money and We have got lots of systems that already work, the question is how to pull all the information together, ' says Philip Firth, information management and technology strategy implementation manager at Wrightington, Wigan and Leigh trust.

'Our EPR approach is best of breed and XML gives you all the flexibility you need to implement that.'

The three big issues when looking at this approach are how to integrate many different systems across a trust, how data should be presented and how to input data.

'We have addressed all three with XML, ' says Mr Firth.'We have every level of patient information in the system, and you would expect that, and we also have the flexibility to develop interfaces for small, individual stand-alone systems as well.'

The Wigan system is based on CSW Case Notes, an XML-based, eGIF-compliant product that integrates information held in legacy systems into a flexible and secure clinical repository.

Authorised clinical users can view relevant patient history, current treatments and planned activities from any browser-enabled device. It holds diabetes records, pathology results and patient alerts. ECG reports are scanned in as part of the system and data is also pulled up from a stand-alone system in the cardiology clinic.

'In NHS terms, this system cost next to nothing, ' says Mr Firth.'We have gained an entire level-3 system for less than£1m.'

Mr Firth is convinced this is the way forward in developing EPRs, but he sounds one note of warning: it is important to have technically competent people in the team that can implement such a system.

He says the training provided by supplier CSW was invaluable in enabling his team to now be able to configure core modules and develop new systems quickly and easily, without external support.

REFERENCES 1Mathieson S.Web feat. HSJ e-novation 4 July 2002; 112 (5812);2-5.