FrontPoint Systems Ltd

The local IM&T plans are due for submission at the end of the month and I thought it would be interesting to see the guidance from the DH on preparing them.

Also, the deadline for the submission of responses to the Commons Health Select Committee review of the National Programme for IT is the 16th.

Choose & Book comes in for some stick.

NHS South East Coast said figures for last November showed 24% of referrals were made using the “choose and book” system, against a target of 59%.

It indicates the South East has the second lowest take-up rate in the UK for the scheme.

A reminder of what errors in judgement look like in the Times.

Taurus is not a word to mention lightly to older denizens of the London Stock Exchange. It was the code name for a grand project to replace the overstretched back offices of stock market firms with a fully computerised settlement system. The project stalled ahead of the 1986 Big Bang, then multiplied in scope and complexity as the various participants insisted that it cover all known contingencies and variations. Finally, after many delays, it was readied for stress testing and failed miserably. It was the pioneering big computer project disaster. If only the NHS, for instance, had examined why it went wrong, it might have saved billions.

Some encouraging news from Winchester that Millennium is becoming “more robust” but this is a statement from the IT lead & refers only to the PAS system. I wonder what the clinicians have to say.

I think I have previously mentioned the parlous position of Choose & Book in the GP contract negotiations but it is worth a reminder.

The nebulous state of access restrictions on patient data even under the new privacy schema is highlighted by Dr Thornton. This ties in with what I have said before, headlines all being very well, give us the detail.

A reminder again of the study by Professor Pamela Briggs, from Northumbria University:

Researchers found people use an initial weeding out process to deal with the minefield of health information of variable quality available. However, this tends to mean they quickly eliminate most NHS and drug company websites, they said. The study was funded by the UK’s Economic and Social Research Council.

The researchers examined the internet search strategies of people who wanted to find specific health information on topics such as high blood pressure, the menopause and hormone replacement therapy (HRT).

They found that many websites were dismissed at quite amazing speeds.

“One thing that really put people off was advertising, so people clicked off drug company websites straight away.

“People don’t have the patience to scroll through pages in order to find something useful.

“Ease of access is so important.”

Something to consider when building resources but also hopefully something that good designers have had in mind for a long time.

An interesting story on the marriage of digital dictation & workflow, given my past interest in the field.

The CUI project gets some airtime.

The NHS CUI project is intended by CfH to provide a standard user interface for clinicians using different clinical systems across the health service. EMIS is to become the first major clinical software vendor to the health service to incorporate elements of the new NHS Common User Interface (CUI), developed by Microsoft on behalf of Connecting for Health, into its software.

In the long term the vision was of a single user interface across the NHS. “This will probably not be completely standard but have standard elements so that if you want to look at a patient’s details you’ll be looking at a standard screen.”

Good for Microsoft, good for providers with Windows solutions, though I wonder if it will be available for Linux. And I am yet to see a proper implementation as well as the fact that Microsoft’s UI designers have not exactly had stellar reputations niggles at me.

A feel good story about innovations in medical IT in the Guardian but which also points out they happened inspite of and not because of CfH.
As I have previously pointed out, trusts & the DoH combined forces to strangle so many other ideas at birth.

And the starting gun has been fired.

Approximately 14,500 patients will have a summary of the GP record, containing details of name, address, medication history, serious illnesses and allergies, uploaded to a national database unless they choose to opt-out during after an eight week consultation period beginning today. Letters and leaflets explaining the programme will go out in the next few weeks.

By July, eight weeks after the end of the consultation phase, Bolton’s out-of-hours provider and A+E department will be able to view the summary record.

Professor Mike Pringle one of the two clinical leads behind the project told E-Health Insider: “This is the starting gun for the early adopter programme for the Summary Care Record.” He said he expects a total of seven PCTs to be involved in the programme by the end of the year.

The first two practices are Keardley Medical Centre and the Kirby, Page, and McMillen practice, Bradshaw Brow. Both practices use InPractice Systems GP software. Other practices, initially from Bolton PCT, will follow over the next few months.

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Choose & Book gets its share of the headlines on what appears to be a slow news day with the Guardian running a piece on the divisiveness of choice.

The government wanted 90% of referrals by GPs to run through the system by March, but usage is well below that. However the figures hide a more complex picture, with some GPs enthusiastic about the system and others critical.

Usage is currently at 37% and he now expects the 90% target to be met nationally later this year.

…half of GPs use the system for more than 40% of referrals. But among these regular users, 90% say it increases the time taken to refer a patient to hospital and 70% think it is detrimental to patient care or makes no difference.

For something that is not so directly influential in patient care, C&B gets more than its fair share of mostly negative attention precisely for that reason. Most clinicians cannot understand the focus on C&B when there are far more pressing needs in the system, even more so when the manipulation of appointments etc. to manage demand detract from its supposed focus.

E Health Insider has a similar story focussing on a recent BMA survey.

The unpublished survey of 279 GPs and 128 consultants carried out between 30 November 2006 and 10 January this year shows that members’ views have changed little since then. Of those who responded to the survey, 78% of GPs and 77% of consultants said they currently used Choose and Book.

A total of 57 % of GPs and 81% of consultants described their experience of Choose and Book over the previous month as negative or very negative and 87% of consultants and 71% of GPs said they would not recommend Choose and Book to a colleague.

Asked about whether patient choice had improved with Choose and Book the majority of GPs (68%) reported that in their view it had not as did 56% of consultants with a further 30% of consultants saying that they did not know.

Consultants appear to be even unhappier with the e-booking system’s impact on patients than GPs with almost 92% of consultants disagreeing or strongly disagreeing with the statement that patient feedback had been generally positive compared to 64% of GPs.

I would consider this a minor indicator of the state of affairs considering the small sample size and the fact that the response rate was quite low. However the results are similar to previous surveys of this nature & illustrate why it is not performing.

One GP commented: “We have just decided to stop, having been in the top 100 practices for usage, as the local hospital has started to tell patients that there are no appointments available, when the patient rings to book, and asking the patient to contact our practice! - what are we supposed to do?’ Another said: “Complaints from patients over difficulties in getting through . . . all of this fed back to me in wasted surgery time.”

There is also coverage of the slow progress of Isoft’s Evolution Maternity Information System with the pilot customer dropping it.

Royal Shrewsbury Hospital NHS Trust, Shropshire, which has been waiting for almost two years for its local service provider Computer Sciences Corporation to implement iSoft’s Evolution MIS have now deployed the Eclipse system from Huntleigh Diagnostics in a bid to save up to £0.5m annually through reduced clinical negligence liability costs.

In other medical news, the Telegraph highlights the scheduled march in both Glasgow & London at the weekend.

There is also some tough talk from the Healthcare Commission in the Telegraph re the issue of hospital acquired infections. The point that most healthcare professionals would make though is that what is required is a re-imagining of care processes with the patient being the centre of the web & attention being paid to providing the best care, not frequent transient campaigns when something becomes too hot to handle. Sloppiness is now a part of the chain, exacerbated by the pressures on staff & improvements in one area are accompanied by an increase in failings in others.

High bed occupancy increases the risk of infection. The survey showed that when bed occupancy was over 85 per cent cases of MRSA were 16 per cent above the average. Where bed occupancy rates are more than 90 per cent MRSA infection was 42 per cent above average.

The commission is proposing that trusts will have to show that they are fully complying with the NHS hygiene code which includes guidance on hand washing, staff education and involvement in infection control at board level.

I had missed this one about United Health earlier but nice job if you can get it, pity about the departure under a cloud but $2 billion would keep me cocooned from it all.

I have a feeling that this price for DEXA scans is going to cause a few furrowed brows at the PCT’s who will be paying more for the same procedure through the Diagnostics IS contracts. Time to get the calculators out again?

A quick reference to the cost of the war in the Independent & how the money could have been put to better use paying for healthcare.

“This is the politics of Mad Hatter priorities,” said Alan Simpson, a Labour opponent of the war. “The Government is throwing money into an unwinnable war zone in Iraq at the same time as withholding money that creates a war zone in our hospitals.”

The state of the British smile got a mention in the Mirror who review the NHS dentistry contracts, brought on by this non-story. The performance figures for the dental contracts are here.

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The world at large got a glimpse of the damage control ongoing after Andrew Rollerson’s description of the CfH programme as

in danger of delivering “a camel, and not the racehorse that we might try to produce”, as he told a parliamentary committee that this can only be solved with more ‘visionary and proactive leadership from the NHS.’

Good luck with that search, there is more chance of me winning the lottery.

I expect the minutes of the session to turn up here but for the moment, let’s go with the report.

Andrew Rollerson, who was credited as ‘formerly practice lead of the healthcare consultancy at Fujitsu’ , told the Commons Public Accounts Committee that he had faith in NPfIT but felt some issues needed correcting first.

He has since been suspended from his duties by the company, pending an internal inquiry which could lead to disciplinary procedures.

Yup, shoot the messenger for the message.

He revealed to the committee that Fujitsu, local service provider for the Southern cluster, had found NPfIT a difficult project to manage.

“If NPfIT was left to IT departments to control, it would fail because the end users would not be engaged. If we’re not careful the driver will become the technology itself.”

An understatement if ever there was one. The dialogue with the users in the NHS needed to happen before the system requirements were set out & contracts signed. Anything else had no chance whatsoever as too many compromises would have to be made. Watch out for similar problems from the ISTC programme, especially the data integration between the new private sector facilities & the CfH solutions, both of which do not propose to deliver the actual requirements of clinicians on the ground.

Rollerson spent all of his time away from the hearing surrounded by senior colleagues from Fujitsu. He told the committee that he felt reporting in Computer Weekly was out of context from what he thought was a presentation intended to be supportive of the national programme.

Using another analogy, he said that it was like designers at Boeing who were considering replacing the 747 with a jumbo jet, before realising that a new design would be a much better and effective design for everyone involved – CfH should look at NPfIT in the same sort of light as this.

So are we going to get a proper review of the programme? One that involves stopping the waste of money that the current one is?

I’m not holding my breath.

Video of that committee.

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The Guardian has picked up on the story first broken by E-Health Insider that CfH will be tendering for alternative approaches to electronic medical records.

E-Health Insider

Plans for a catalogue of ‘additional systems suppliers’ covering a wide range of specialist clinical systems are in the final stages of being drawn up by Connecting for Health (CfH), the agency responsible for delivering the £12.4bn NHS National Programme for IT.

E-Health Insider understands that the supplier catalogue plans being drawn up may cover all major departmental systems and clinical specialities, together with areas such as A+E, maternity and theatres. Services such as acute data migration and infrastructure are also thought to be covered.

Sources indicate that the plans – being termed Additional Systems Capacity and Capability (ASCC) – are at an advanced stage of development. “Granger’s [Richard Granger, head of CfH] team are working on it at the moment and trying to work out the details,” one senior source told EHI. “It’s in the pipeline.”

EHI understands that if negotiations are completed the plans could potentially due to be unveiled within weeks with an OJEU (Official Journal of the European Union) procurement, similar to that now underway for GP Systems of Choice (GPSoC).

CfH told E-health Insider: “Yes. NHS Connecting for Health is currently formulating an OJEU in support of the “Supplier Catalogue” announced by Richard Granger in October 2006. It is anticipated that this “Additional Services Capability and Capacity” (ASCC) OJEU will be issued during March. The GPSoC model, based on systems having to meet interoperability criteria and deliver broadly defined levels of functionality is thought to provide the template for the new catalogue.”

The Guardian

The NHS will start recruiting alternative software suppliers to its troubled £6.2bn IT upgrade project this month, in a move which could see the government’s vision for a single IT system for the health service in England unravelling.
The move is a tacit admission that a fully integrated IT system may never be completed. NHS bosses had until recently discouraged hospital trusts from deserting the scheme. But disaffection is now so widespread and delays so long that officials are working on a list of accredited alternative suppliers, which is widely seen as a move to appease hospital trusts.

Under the government’s National Programme for IT (NPfIT), trusts were promised centrally bought software to be installed from mid-2004 - all free of charge to them or heavily subsidised. As a result, hospital trusts held back from buying new systems, content to get by with their old software in the belief that NPfIT would soon deliver replacements. But these have now been delayed for so long that trusts are seeking alternatives.

Trusts essentially stopped considering independent procurement from early 2001 leading to the early death of numerous innovative solutions, most of which could not recruit customers for love or money. I should know, I was leading one of them. There is very little likelihood though that I will be resurrecting my plans, even though I feel distinctly underwhelmed by most of the products on the market. There are far better ways for me to waste my time unless there is a radical change of personnel & policy at the DoH & CfH.

I wonder though how much of this IBA will take this into consideration when pricing Isoft as Lorenzo might not have much of a market when it is finally out of the incubator.

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Finally something about IT, I was getting a bit concerned.

E-Health Insider carries news of guidance issued to the SHA’s about the detail of the Summary Care Record Service i.e. the Spine.

The gist is that

Patients can choose to dissent from data sharing, in which case a patient’s summary record will be restricted to the authoring GP only.

If patients do not opt-out an initial text based summary of their medications, allergies and adverse reactions will be uploaded to the spine.

After the upload patients have two options. They can choose to remove some items from their summary record, known as ‘tailoring’ and done by the clinician, or they can send a blank summary update which includes demographic information only and a message that the patient has chosen not to have a summary record.

So patients can consent to sharing their summary, dissent from sharing but still have the information uploaded in case they change their minds or dissent from sharing and have no summary uploaded.

I wonder why it took so long to get to this stage, these principles are the ones that should have been applied from the start. Though there is still the opt-in v/s opt-out issue.

The first wave of the early adopter programme will begin in the first quarter of 2007/8 with a small number of practices in one PCT, followed by roll out to more practices in that PCT and the trial of the programme in a second PCT. In the last two quarters of the year second wave practices will go live with the SCR. Access to the SCR via Healthspace will be available from May or June 2007.

But considering that the initial consultation with patients to gain consent for data sharing is currently taking 2 hours, I wonder how this will work in practice. Not to mention the issue of exclusion -

“Dr Hannan admits the system isn’t for everyone, though. He has many patients from the Bengali population - and none of them have so far come forward for internet access to their records.”

And there still is no clarity about the governance arrangements & the resources available to the Caldicott Guardians or others taking on the governance role.

There is also the Guidance from the DH on preparing local IM&T plans. I struggled to find guidance on obtaining actual clinical input into these plans.

Also, some detail previously released by CfH about Sealed Envelopes and the philosophy behind them .

See the new Private Eye dated 2 March - 15 March for a ripping yarn on the tribulations surrounding the NHS IT programme. The article is not available online but I hope to do something about that soon. The image posted below is blurred on purpose to avoid copyright issues.

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E-Health Insider reported the other day on the ongoing auction for Isoft which I touched upon earlier this year.

So we have McKesson being the frontrunner with IBA Health & General Atlantic in with an outside chance. But it appears that IBA might have something up its sleeve, going by the report in the Guardian today and the Financial Times today which reveal that an all share offer might just be going forward after all.

I just have difficulty visualising ISOFT as the blushing bride, CSC the stern uncle & CfH the bishop making sure everyone behaves.

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The Times has a followup on the issue of immunisation records not being available in the London area following last years botched implementation of the Child Health Interim Application (CHIA) software by BT.

The health of children is at risk because an NHS computer system wrecked 20 years of accurate immunisation records.

Faulty software introduced in 2005 has left some primary care trusts (PCTs) unable to track whether children have been vaccinated and screened for genetic conditions, raising fears that many are unprotected against diseases. Parents are not being reminded when their children are due for jabs and check-ups.

The Health Protection Agency cannot publish full statistics on the uptake of vaccines because the five worst-affected London trusts cannot provide accurate data.

When the shortcomings of the Child Health Interim Application (CHIA) software were disclosed by The Times a year ago, the Department of Health stated that the problems were being addressed. Staff were said yesterday to be “in despair” at continuing difficulties with the system supplied by BT.

Christine Sloczynska, consultant community paediatrician at Waltham Forest PCT, in East London, said: “I’m sure there will be kids who slip through the net and will be unimmunised. Our immunisation take-up has fallen from 94 per cent to 58 per cent, but we don’t know how much it is due to children missing their vaccinations, or to lack of data.”

“We are sometimes told of a child’s death before we know it has been born,” Dr Sloczynska said.

I wonder if there is any way that this problem will be blamed for the UNICEF shocker, though it has already been claimed that the report used old data.

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The guys at Fujitsu are finally facing up to what has been evident to sensible observers for a long long time.

As reported in Computer Weekly, Andrew Rollerson, the healthcare consultancy practice lead at Fujitsu in his presentation acknowledged last week at the “Successful implementation of NPfIT 2007″ (kinda ironic, don’t you think?) conference that there is a “gradual coming apart of what we are doing on the ground because we are desperate to get something in and make it work, versus what the programme really ought to be trying to achieve“.

“There is a belief that the National Programme is somehow going to propel transformation in the NHS simply by delivering an IT system.Nothing could be further from the truth. A vacuum, a chasm is opening up. It was always there.”

Rollerson said there was a danger that suppliers would end up delivering “a camel, and not the racehorse that we might try to produce“

At this stage, I would be happy even with a camel, you can still use it for transport. What we are in danger of receiving is a moribund pensioned off white elephant that sucks up all available resources & leaves no room in the ecosystem for another try at getting a decent IT system that delivers the required functionality.

Who will join me in laying the blame right at the door of CfH & the talking heads who negotiated this deal? I don’t see many of them crowing now about how this contract was a masterpiece of negotiation. But no doubt the spinners will be out in force to shovel this under the carpet as they have done innumerable other criticisms. And there will be a knighthood or other honour for those involved at a later date.

As questioned by Martyn Thomas, a Visiting Professor in Software Engineering at Oxford University who is one of the 23 computer scientists referred to previously here, “If sharing smartcards is secure, it should have been in the security policies from the start. If context switching can be unacceptably slow, there should have been explicit upper limits for the time allowed, stated unambiguously in the specifications. So: did the specification omit this essential requirement (in which case, what other essential requirements have been overlooked?); or did the output-based specification state a time limit that has not been achieved? Or did the output-based specification specify a time limit that was too long in practice (in which case, what else have they got wrong by failing to prototype adequately before letting contracts?).”

Which brings me to my first rule of procurement, one I am sure most people are familiar with: Know what you want to buy and whether you really need it! And make sure that your specifications reflect this. I will have more to say on this subject with reference to the ISTC procurement programme currently under way.

Perhaps David Nicholson ought to have a rethink.

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The Commons Health Select Committee is to hold an inquiry into the Electronic Patient Record being provided by Connecting for Health.

“The inquiry will focus particularly on the following areas:

• What patient information will be held on the new local and national electronic record systems, including whether patients may prevent their personal data being placed on systems;

• Who will have access to locally and nationally held information and under what circumstances;

• Whether patient confidentiality can be adequately protected;

• How data held on the new systems can and should be used for purposes other than the delivery of care e.g. clinical research; and

• Current progress on the development of the NHS Care Records Service and the National Data Spine and why delivery of the new systems is up to 2 years behind schedule.”

The deadline for submissions is Friday 16 March 2007.

Having long argued for a bottom-up approach to its development rather than the edifice with rotten foundations we have been lumbered with, it is time for me to start writing.

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Underlining what I have been saying about the lack of joined up thinking in the development of healthcare IT solutions & its implications for security, the Scottish Cervical Call-Recall System (SCCRS) has had to delay the roll-out of its new patient records system being developed by Atos Origin.

“In an exclusive story this week, BMA News reveals that anyone with a password, including admin staff, would be able to access smear results under the Scottish Cervical Call-Recall System that is currently being piloted in a handful of GP practices.

Forth Valley GP Brian Keighley said: ‘This is unacceptable and quite possibly illegal and I don’t think GPs should cooperate with this.’

The new system, which was due to be launched in May, has how been postponed. NHS National Services Scotland’s medical director for e-health Brian Robson told BMA News the roll-out would be delayed until all problems were solved. He said: ‘ This is not an acceptable situation. I can give an assurance on behalf of National Services Scotland that [the system] will not be launched until this is sorted out.’

IT hitches such as whether GP computer systems would be ready for the system and whether GP online training for using the system was suitable have also contributed to the delay.”

As I have pointed out before, security starts at the design stage. Talk to your users before, during & after any changes. Review the entire project regularly, including even the most basic assumptions. Which is one of the reasons why I favour “Iterative” development over the “Waterfall” methodology.

Also, CfH had another of their roadshows yesterday in Birmingham, another top down lecture on how their solution is the greatest advance since sliced bread & how everything is just great. What is & has long been missing is the willingness to listen, to take on board the criticism of the programme & change course where needed.

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