The evolution of Electronic Patient Records in the NHS, 1988-2003

Matthew JonesJudge Institute of Management

University of Cambridge

An EPR by any other name …

• 1988– Hospital Information Support Systems (HISS)

• 1994– Electronic Patient Record

• 1999– Electronic Health Record

• 2002– Integrated Care Record

• 2/12/2003– NHS care record

NHS IT strategy

• 1992 – “Getting Better with Information”

• 1996– Implementing the infrastructure for IM&T in the

NHS

• 1998 – “Information for Health”

• 2002 – “Delivering 21st Century IT support for the NHS”

1988 HISS programme

• £56 million on the Initiative• £48 million in financial support to 16

projects at 25 hospitals• £32 million on 3 main pilot projects, at

Nottingham, Darlington and Greenwich.• Significant delays in implementing key

systems• National Audit Office inquiry

1992 “Getting Better with Information”

• Linked to White Paper “The Health of the Nation”

• Strategy guided by key principles:• Information will be person-based• Systems may be integrated• Information will be derived from operational systems• Information will be secure and confidential• Information will be shared across the NHS

• Strategic initiative• Developing an IM&T infrastructure

1994-1997 EPR programme

• Demonstrator Projects, notably Queen’s Hospital, Burton and Wirral Hospital achieved successful hospital-wide implementation of EPR– Clinical focus– Strong management– Management/clinician partnership

1998 “Information for Health”

• “Lifelong electronic health records for every person in the country”

• “Round-the-clock on-line access to patient records and information about best clinical practice, for all NHS clinicians”

• “Genuinely seamless care for patients through GPs, hospitals and community services sharing information across the NHS information highway”

Specific Targets

• Developing and implementing a first generation of person-based Electronic Health Records, providing the basis of lifelong core clinical information with electronic transfer of patient records between GPs

• Ensuring that all acute hospitals have the ability to undertake patient administration, including booking for planned admissions, with an integrated patient index linked to departmental systems, and capable of supporting clinical orders, results reporting, prescribing and multi-professional care pathways

• All acute hospitals to have level 3 EPR by 2005 (35% by 2003)

2000-2003 Electronic Record Development and Implementation

Programme (ERDIP)• Demonstrator sites• Key projects include

– 24 hr care, patient access, EHR– level 6 EPR– integrated primary & community care– direct booking, referrals, discharge,

pathology messages   – technical standards

2002 “Delivering 21st Century IT support for the NHS”

• Patient centred delivery of services • Effective electronic communications, … cut

the time to find essential information (notes, test results) and make specialised expertise more accessible for staff

• Improve management and delivery of services by providing good quality data to support NSFs, clinical audit, governance and management information

Integrated Care Record System

• Cross setting (including social care), multidisciplinary– “no more silos”

• National programme– Emphasis on infrastructure and “ruthless”

standardisation• 700-page comprehensive specification for ICRS• Single system for whole SHA

– Efforts focused on letting contracts for National Application Service Provider and Local Service Providers

Discussion 1

• Onwards and upwards?– Progressively wider scope

HISS EPR EHR ICRS

Hospital admini-stration

Hospital Primary + Secondary +

Community

NHS (+ social care)

• Does this mean that EPR use has ‘evolved’ in practice?

• Difficult to see much evidence of ‘progress’ for the NHS as a whole• Big differences in EPR use between

hospitals• Not necessarily related to quality of

management • Investment decisions made by individual Trusts

• Some successful initiatives, but usually highly localised

• Rarely diffused more widely

Why?

• Priorities distorted by other initiatives (and IT low on the list)• Performance measurement/ League tables• Clinical governance/Clinical Audit• Modernisation/E-government

• Lack of consistency• Implementation approaches • Strategy focus

• Competing healthcare IT functions• Information Authority• Information Policy Unit

HISS EPR EHR ICRS

Implementation approach

Pilot projects Decentralised Pilot projects

Centralised

Strategy focus Infra-structure (data model)

Developing working record

Developing working record

Infra-structure (standard hardware)

Lead organisation

Information Management Group

Information Policy Unit

Information Authority

National Programme for IT

Issues• Build it and they will come• Organisational change neglected

• Lack of communication• Experience not shared• NIH syndrome

• Unrealistic targets• Aiming for the impossible, by tomorrow• Little evidence of learning from failure to meet• The best may be the enemy of the good

• Speed of response• vs technology change• vs policy change