How to buy: clinical portals could help patient information drive

The rise and rise of the clinical portal in the NHS has been driven both by the end of the national programme for IT and now by the new information strategy. If there is not a portal near you now, there soon will be.

Portals are essentially web pages that allow clinicians and managers to view information from different IT systems. That might be different clinical systems such as laboratory, pathology and radiology to give clinicians a view of a patient’s test results within a hospital, or systems in other organisations –such as acute and community – to give an overview of a patient’s care pathway.

In some systems, users can not only view information but interact with it too. Information can be anonymised for managers, researchers and reporting.

As Wayne Parslow, general manager for Harris Healthcare Solutions, which recently acquired portal providers Carefx, explains: “A portal is a web page that sits on its own repository of information and allows you to search it.

“In the case of healthcare, it has built into the information governance surrounding who can access that information and the systems to keep it secure.”

Portals are seen as a way of connecting existing information sources into a single view and are therefore cheaper than replacing core IT systems.

The information strategy underpins their development with a philosophy of information sharing and the promise to develop information standards and enforce the consistent use of NHS numbers, which allow patients (and also therefore their records) to be uniquely and correctly identified.

Jeremy Nettle, chair of the Intellect Healthcare Group, which represents the technology industry, and former director for portal provider Oracle Corporation Healthcare, says: “There has been so little funding for replacement IT systems in the NHS and portal technology is really coming into its own now, in particular where hospitals have merged. The market growth is massive.”

Best of breed

Dr Lloyd McCann, medical director for Harris Healthcare Solutions, adds: “It seems there are two religions about portals, particularly in acute trusts. There are those who are looking at fairly ageing IT infrastructure and would really like to throw out their old stuff, the laboratory information system, order communications, radiology information system and their patient adminstration system. By slapping a browser interface on them, they can effectively create an electronic patient record for a much smaller cost.  That’s where about half the trusts want to go.”

Such systems allow clinicians single sign-on to the portal, where they can see all the relevant information about a patient linked to a clinic appointment or inpatient episode. Clinicians can launch individual clinical systems from within the portal if they need to update records, with the data feeding immediately back into the portal view.

James Norman, director of information management and technology at the Royal Liverpool and Broadgreen University Hospitals Trust, does not agree with the ageing infrastructure premise.

“We have best of breed clinical systems here and we have no desire to go through all the pain and expense and retraining that would be involved in replacing them,” he says.

So the trust is developing a portal with Harris that will link them, and in effect, create an electronic patient record. The security, information governance and context management remain within the individual applications and there is no training required.

“If you can use a web browser you can use the portal,” Mr Norman says. “We are adding new systems on a weekly basis and people are using them immediately.” Consultants report they are saving 30 minutes in each four-hour clinic by having the single patient view and not having to switch between systems.

The other half of trusts, says Dr McCann, want to get better use of their existing technology and tend to develop portals on a use case basis – for example, a portal at a regional cancer centre that allows referring hospitals to view images or GPs to view test results.

Mr Nettle argues that the NHS number issue is a crucial starting point for anyone buying a portal. Portals can only really work if the people using it can be sure they have the right patient’s data in front of them. “The weakness we still have is that even though the NHS number is mandated, only about 35 per cent of the NHS uses it,” he says.

But buying a portal is much more than putting together a web page, he adds. “Quite a few organisations are looking for portal technologies without understanding the integration aspect or the massive data quality and validation exercise that needs to take place,” he says.

Mike Fuller, marketing director of InterSystems, another portal provider, agrees. “The portal is just the tip of the integration iceberg,” he says. “Organisations think they are buying a portal but really they are buying an integration project and project management.”

There are also questions about optimising the view. What might be good for a doctor will not work for a patient, says Mr Fuller. A portal view that is useful to consultants in an outpatient department is unlikely to look the same as a portal page for a radiologist, even if they are dealing with the same information.

Mr Parslow advocates building “gadgets” – think the MyGoogle homepage. Not only would this allow users to change their view according to their needs but could also transform “read only” portals into something much more useful.

“Most portals are ‘read only’ but there is a demand for transactional portals,” he says. Patients may want, for example, to book an appointment via a portal; a GP may want to order a diagnostic test.

“We are starting to see gadgets develop,” he says. “We are advocating using open source software with clinical information.”

But, adds Dr McCann, the wider drive is to connect communities. “Every conversation we have right now tends to be about how we extend to a regional level,” he says. For example, Northern Ireland recently announced it was to develop a province-wide electronic healthcare record based on portal technology. A £9m seven-year contract with Orion Health will see systems linked across acute, community and primary and social care to create a single record for 1.8 million people.

Do it yourself

Scotland already has a number of portals that span several health boards or cover the whole of the country for specific conditions, including diabetes and renal services. In Lothian, the NHS and social care sectors are working with Harris Health Solutions to integrate their information via a portal.

Dr McCann predicts that in future, there will be an emerging market for portal integration as healthcare communities attempt to set up county-wide portals.

“There is currently no system that can do that and there are many layers of complexity involved,”  he says. In short, there are a multitude of questions facing any organisation – or group of organisations – planning a portal.

Those who already use portals are often advocates of the technology but, equally, will warn that developing them is hard work. One question that comes up again and again is: should trusts develop in-house or go to a commercial supplier? A lot of portal technology, like the web, is open source, lending itself to a do it yourself approach.

Rhidian Bramley, chief clinical information officer at The Christie hospital and a consultant radiologist, has built several portals for his trust with his in-house development team. They variously link 40 trusts for viewing Picture Archiving and Communications System images, allow GPs and clinicians in referring hospitals to see patient records, and will soon be extended to hospices and possibly patients, too.

He says one advantage of in house development is clinical engagement. Dr Bramley is a known and trusted clinical colleague and, being on site, can make micro changes to the portals as they are developed.

“We have resisted doing it through outside suppliers with contractors and projects because we wanted an agile approach and iterative development,” he says. “We have found that even though we defined the requirements up front, by the end of the project those initial requirements have turned out to be a fraction of what we needed. It works for us and I would certainly recommend it to others.”

Over at Worcestershire Acute Hospitals Trust, director of ICT John Thornbury has a different view. He has been working on a county-wide healthcare portal for many years, with much of the development in house.

“If I was doing it again, I would probably go to a commercial supplier because of the time and effort involved in all the checks around the data and risk of mismatching patients,” he says.

This brings us back to Mr Nettle’s point about the NHS number. Mr Thornbury says: “The key things are data quality, data quality and data quality. If anybody is building a portal, they need to make sure they have a robust enterprise-wide master patient index.”

Like Dr Bramley, he says developing a portal requires good clinical engagement. “You must work with the clinical community and deliver what they want,” he says. “And keep things simple otherwise you will never deliver. It will grow with the clinicians as it is only when they can see what it can do that they realise what they want. We take a very pragmatic approach working with clinical champions.”

Mr Norman, meanwhile, urges trusts to look first at their existing IT. “Take stock of what you have. If you have capable systems that are doing the job, even if they are not best of breed, you might be able to use portal technology and avoid a complete replacement of your systems.”

The ability to customise the data view and to allow clinicians to see “their” data is also crucial. “Make sure you are building it from the clinician’s perspective,” he says. “They will scupper it if you try to impose a portal on them, if it does not work or if it is more complex than what they were using previously.”