This project will be a detailed analysis on the NHS' Electronic Patient Record (EPR) implementation programme.
CONTENTS
Introduction to the Project and Definition of the organisational Change Problem being addressed by the Project 1
.1 Project Rationale 1
.2 Definition of Organisation Change Problem 1
2 Analysis of the Problem situation 1
2.1 Strategic Problems in the NHS 1
2.1.1 Criticism of the NHS 1
2.1.2 Waiting Lists 2
2.1.3 Quality Control Problems 2
2.1.4 Failure to Exploit Information Technology 2
2.2 Operational Problems in the NHS 2
3 Definition of the IS solution to the chosen business problem (s) 3
3.1 EPR, EHR, ICRS and NPfIT 3
3.2 Electronic Record Development and Implementation Programme (ERDIP) 4
4 Identifying the correct organisational change issues 5
4.1 Overview 5
4.2 Changes to NHS Structures 5
4.2.1 Creation Of Primary Care Trusts (PCTs) 6
4.2.2 Creation Of Strategic Health Authorities 6
4.2.3 Regional Directors of Health and Social Care 7
4.3 Ensuring Quality of Service Delivery 7
4.3.1 National Institute for Clinical Excellence (NICE) 7
4.3.2 Commission for Healthcare Audit and Inspection (CHAI) 7
4.4 Improvements to Operational Procedures 8
4.5 Changes Needed to Procure and Operate the New Information Systems 8
4.5.1 Changes in NHS Structures 8
4.5.2 Service Providers and Clusters 8
5 Process Models 9
5.1 Primary Care Information Flows 9
5.2 Winchester Direct Cataract Referral 10
6 Evaluating what business improvement occurred 13
7 Evaluating the impacts of the organisational change upon business improvement 14
8 Statement as to how solution meets the project's requirements 14
9 Record of time spent on project and types of activities against plan 16
0 Evaluation from the whole group on the project, the team and their effectiveness 21
1 Personal evaluation and reflection by team members 22
1.1 Personal reflection - Manal Al-Eid 22
1.2 Personal reflection - Brian Probert 23
References 24
Appendix 1 - Project Plan 26
INTRODUCTION TO THE PROJECT AND DEFINITION OF THE ORGANISATIONAL CHANGE PROBLEM BEING ADDRESSED BY THE PROJECT
.1 Project Rationale
This project will be a detailed analysis on the NHS' Electronic Patient Record (EPR) implementation programme. The implementation programme has been undertaken by the NHS as a means to improve its very much failing health service and the aim of EPR is to provide a unified national database of the relevant details of each and every NHS patient.
The NHS was chosen as the organisation to look at as it is the third largest employer in the world and as a result and as a result any changes that they undertake would have to be on a massive scale. This gives the team members of this project an opportunity to show the many different changes the NHS will undertake in order to suit the requirements of each and every working department within itself.
.2 Definition of Organisation Change Problem
As discussed in section 4, the first goal of these organisational changes is to reduce inequalities - especially regional inequalities - through the mechanism of nationally applicable clinical standards which are set centrally by the NHS and the Department of Health.
The second major goal is to have a more "patient-centred" service and this requires improved patient mobility between different organisations. Cancer Networks - as described in section 4.2.2 are a particularly good example of this.
To facilitate improved patient mobility, improved information flow is required also (section 5) and this has strengthened the case for the Electronic Patient Record (EPR) and its more advanced forms, the Electronic Health Record (EHR) and the Integrated Care Records Service (ICRS) which are defined in section 3.
2 ANALYSIS OF THE PROBLEM SITUATION
2.1 Strategic Problems in the NHS
The NHS was established in 1948, and it is believed to be the largest organisation in Europe. The World Health Organisation acknowledge that NHS is one of the best health services in the world. NHS was formed to provide health services to the rich and poor. This concept was introduced to eliminate priority given to health care based on your social class.
2.1.1 Criticism of the NHS
Over the years the government has received several criticism from the opposite parties, health professionals and public, over its handling of the health service. The NHS has severe quality failures, clinical negligence and inequality in resource allocation and recruitment retention difficulties. Poor performance against international benchmarks such as MRSA (multiple antibiotic-resistant Staphylococcus Aureus.) has been outlined. MRSA is a bacteria, which causes infection which are sometimes fatal, which may lead to a growing problem for the NHS. In England alone there are more than 7,000 cases a year. MRSA rates in the UK are nearly 50 times higher than in the Netherlands, Dutch hospitals take a zero tolerance with MRSA. (BBC, July 2004)
2.1.2 Waiting Lists
Waiting lists have been a major problem for the government - the government has tried to bring the UK into line with European averages but unfortunately it has failed miserably, recently it has been reported that the waiting lists have dropped it has also been confirmed that some hospitals are tampering with the figures. Waiting lists demonstrate that the NHS doesn't have a coherent health information infrastructure. The other problem is post code lottery- quality of treatment depends on where patients live- patients can only receive treatments within their region.
2.1.3 Quality Control Problems
The NHS has undergone a serious battle with quality control. Lack of quality control leads to malpractice claims and problems like the Bristol Royal Infirmary. The surgeons at the centre of the Bristol heart babies scandal were like "captains of a ship" who carried the blame for a failing system, a leading cardiac consultant said. James Monro, the president of the Society of Cardiothoracic Surgeons, said problems "from the very top right down to the coalface" had contributed to the unnecessary deaths of children at the Bristol Royal Infirmary (Telegraph. 18th July 2004).
2.1.4 Failure to Exploit Information Technology
"Historically, the NHS has not used or developed IT as a strategic asset in delivering and managing healthcare. While there were good, usually local, IT initiatives sponsored by enthusiastic visionaries, these were outweighed by the overall lack of funding and development priority given to IT at all levels. Good experiences were not captured, and successful implementations were not scaled from their local beginnings to NHS-wide application." (NHS June 2002 paragraph 2.1.1)
Although the NHS has many systems procured at a local level, these have not been integrated and many have not been updated to use new technology such as Windows. Staff using hospital systems will find that they have a different sign on for each one. Patients will be repeatedly asked to supply the same information. Cross-patient queries which could yield valuable performance data e.g. for comparison with NHS targets may be difficult to carry out.
2.2 Operational Problems in the NHS
The following quotes give some insight into the operational problems which exist in the NHS as a result of their failure to modernise IT systems.
"Barts and The London is one of Britain's top teaching hospital trusts. Our mission is literally to bring excellence to life - to give patients the best possible care so that they can live better, fuller, longer lives." (Barts Hospital web site)
However, the quality of their care - which is not challenged here - appears to be achieved in spite of rather than because their medical records ...
"We found serious problems with the availability, quality and organisation of medical records which leads to cancelled appointments, cancelled operations, repeat tests being undertaken and patients being seen without their notes. This represents an unacceptable and serious risk to patients and patient confidentiality, weakens the organisation of patient care and undermines clinical confidence and relationships with GPs." (Commission for Health Improvement (CHI) audit of Bart's Hospital in 2001)
3 DEFINITION OF THE IS SOLUTION TO THE CHOSEN BUSINESS PROBLEM (S)
3.1 EPR, EHR, ICRS and NPfIT
"Information for Health" - issued by the NHS Information Authority (NHSIA) in 1998, drew a distinction between Electronic Patient Records (EPR) and the Electronic Health Record (EHR). The term EPR is used for any electronic record containing patient data collected in a single organisation - e.g. the records held at the patient's GP - while the term EHR is used to describe a single centralised record which brings together a complete history of all the patient's healthcare "from cradle to grave" (paragraphs 2.10, 2.11).
Different 'levels' of EPR were also defined ranging from Level 1 (non-integrated departmental systems) to Level 6 offering clinical decision support together with multimedia records such as X-ray images (paragraph 2.64). The target was set of bringing all acute hospitals to Level 3 (integration of all clinical data within the organisation) by 2005 (paragraph 2.70).
This target was reiterated in "Building the Information Core - Implementing the NHS Plan" (NHS January 2001) which identified the goal of "a vibrant networked NHS ... with level 3 Electronic Patient Records and first generation Electronic Health Records [by 2005]" (p7).
In July 2002, the NHS published a draft specification of the systems which will provide the EHR under the title "Delivering 21st Century IT Support for the NHS - National Specification for Integrated Care Records Service" (ICRS). The new terminology reflects the long term aim of integrating healthcare and social care records into the same system to facilitate continuity of care when - for example - patients are discharged from hospital.
A shorter document issued on the same day (NHS, July 2002b) coined the term "National Programme for IT" (NPfIT) and outlined the strategy for this larger procurement of which the ICRS would form a part.
Two other NPfIT systems are also referenced below when describing changes to NHS processes. These are e-prescribing (electronic transfer of prescriptions to the pharmacist) and e-booking (now known as "Choose & Book") which allows consultant appointments to be booked online by primary health care practitioners such as GPs and opticians.
3.2 Electronic Record Development and Implementation Programme (ERDIP)
Between April 2000, and April 2003 the NHS trialled a number of approaches to implementation of EHR at District Health Authority level. The projects have been reviewed by independent consultant such as PA Consulting and their findings - which are very extensive - are available on CD-ROM and online (ERDIP, 2003). They give a good insight into the technical and organisational aspects of EHR and its potential within the NHS.
Introduction to the Project and Definition of the organisational Change Problem being addressed by the Project 1
.1 Project Rationale 1
.2 Definition of Organisation Change Problem 1
2 Analysis of the Problem situation 1
2.1 Strategic Problems in the NHS 1
2.1.1 Criticism of the NHS 1
2.1.2 Waiting Lists 2
2.1.3 Quality Control Problems 2
2.1.4 Failure to Exploit Information Technology 2
2.2 Operational Problems in the NHS 2
3 Definition of the IS solution to the chosen business problem (s) 3
3.1 EPR, EHR, ICRS and NPfIT 3
3.2 Electronic Record Development and Implementation Programme (ERDIP) 4
4 Identifying the correct organisational change issues 5
4.1 Overview 5
4.2 Changes to NHS Structures 5
4.2.1 Creation Of Primary Care Trusts (PCTs) 6
4.2.2 Creation Of Strategic Health Authorities 6
4.2.3 Regional Directors of Health and Social Care 7
4.3 Ensuring Quality of Service Delivery 7
4.3.1 National Institute for Clinical Excellence (NICE) 7
4.3.2 Commission for Healthcare Audit and Inspection (CHAI) 7
4.4 Improvements to Operational Procedures 8
4.5 Changes Needed to Procure and Operate the New Information Systems 8
4.5.1 Changes in NHS Structures 8
4.5.2 Service Providers and Clusters 8
5 Process Models 9
5.1 Primary Care Information Flows 9
5.2 Winchester Direct Cataract Referral 10
6 Evaluating what business improvement occurred 13
7 Evaluating the impacts of the organisational change upon business improvement 14
8 Statement as to how solution meets the project's requirements 14
9 Record of time spent on project and types of activities against plan 16
0 Evaluation from the whole group on the project, the team and their effectiveness 21
1 Personal evaluation and reflection by team members 22
1.1 Personal reflection - Manal Al-Eid 22
1.2 Personal reflection - Brian Probert 23
References 24
Appendix 1 - Project Plan 26
INTRODUCTION TO THE PROJECT AND DEFINITION OF THE ORGANISATIONAL CHANGE PROBLEM BEING ADDRESSED BY THE PROJECT
.1 Project Rationale
This project will be a detailed analysis on the NHS' Electronic Patient Record (EPR) implementation programme. The implementation programme has been undertaken by the NHS as a means to improve its very much failing health service and the aim of EPR is to provide a unified national database of the relevant details of each and every NHS patient.
The NHS was chosen as the organisation to look at as it is the third largest employer in the world and as a result and as a result any changes that they undertake would have to be on a massive scale. This gives the team members of this project an opportunity to show the many different changes the NHS will undertake in order to suit the requirements of each and every working department within itself.
.2 Definition of Organisation Change Problem
As discussed in section 4, the first goal of these organisational changes is to reduce inequalities - especially regional inequalities - through the mechanism of nationally applicable clinical standards which are set centrally by the NHS and the Department of Health.
The second major goal is to have a more "patient-centred" service and this requires improved patient mobility between different organisations. Cancer Networks - as described in section 4.2.2 are a particularly good example of this.
To facilitate improved patient mobility, improved information flow is required also (section 5) and this has strengthened the case for the Electronic Patient Record (EPR) and its more advanced forms, the Electronic Health Record (EHR) and the Integrated Care Records Service (ICRS) which are defined in section 3.
2 ANALYSIS OF THE PROBLEM SITUATION
2.1 Strategic Problems in the NHS
The NHS was established in 1948, and it is believed to be the largest organisation in Europe. The World Health Organisation acknowledge that NHS is one of the best health services in the world. NHS was formed to provide health services to the rich and poor. This concept was introduced to eliminate priority given to health care based on your social class.
2.1.1 Criticism of the NHS
Over the years the government has received several criticism from the opposite parties, health professionals and public, over its handling of the health service. The NHS has severe quality failures, clinical negligence and inequality in resource allocation and recruitment retention difficulties. Poor performance against international benchmarks such as MRSA (multiple antibiotic-resistant Staphylococcus Aureus.) has been outlined. MRSA is a bacteria, which causes infection which are sometimes fatal, which may lead to a growing problem for the NHS. In England alone there are more than 7,000 cases a year. MRSA rates in the UK are nearly 50 times higher than in the Netherlands, Dutch hospitals take a zero tolerance with MRSA. (BBC, July 2004)
2.1.2 Waiting Lists
Waiting lists have been a major problem for the government - the government has tried to bring the UK into line with European averages but unfortunately it has failed miserably, recently it has been reported that the waiting lists have dropped it has also been confirmed that some hospitals are tampering with the figures. Waiting lists demonstrate that the NHS doesn't have a coherent health information infrastructure. The other problem is post code lottery- quality of treatment depends on where patients live- patients can only receive treatments within their region.
2.1.3 Quality Control Problems
The NHS has undergone a serious battle with quality control. Lack of quality control leads to malpractice claims and problems like the Bristol Royal Infirmary. The surgeons at the centre of the Bristol heart babies scandal were like "captains of a ship" who carried the blame for a failing system, a leading cardiac consultant said. James Monro, the president of the Society of Cardiothoracic Surgeons, said problems "from the very top right down to the coalface" had contributed to the unnecessary deaths of children at the Bristol Royal Infirmary (Telegraph. 18th July 2004).
2.1.4 Failure to Exploit Information Technology
"Historically, the NHS has not used or developed IT as a strategic asset in delivering and managing healthcare. While there were good, usually local, IT initiatives sponsored by enthusiastic visionaries, these were outweighed by the overall lack of funding and development priority given to IT at all levels. Good experiences were not captured, and successful implementations were not scaled from their local beginnings to NHS-wide application." (NHS June 2002 paragraph 2.1.1)
Although the NHS has many systems procured at a local level, these have not been integrated and many have not been updated to use new technology such as Windows. Staff using hospital systems will find that they have a different sign on for each one. Patients will be repeatedly asked to supply the same information. Cross-patient queries which could yield valuable performance data e.g. for comparison with NHS targets may be difficult to carry out.
2.2 Operational Problems in the NHS
The following quotes give some insight into the operational problems which exist in the NHS as a result of their failure to modernise IT systems.
"Barts and The London is one of Britain's top teaching hospital trusts. Our mission is literally to bring excellence to life - to give patients the best possible care so that they can live better, fuller, longer lives." (Barts Hospital web site)
However, the quality of their care - which is not challenged here - appears to be achieved in spite of rather than because their medical records ...
"We found serious problems with the availability, quality and organisation of medical records which leads to cancelled appointments, cancelled operations, repeat tests being undertaken and patients being seen without their notes. This represents an unacceptable and serious risk to patients and patient confidentiality, weakens the organisation of patient care and undermines clinical confidence and relationships with GPs." (Commission for Health Improvement (CHI) audit of Bart's Hospital in 2001)
3 DEFINITION OF THE IS SOLUTION TO THE CHOSEN BUSINESS PROBLEM (S)
3.1 EPR, EHR, ICRS and NPfIT
"Information for Health" - issued by the NHS Information Authority (NHSIA) in 1998, drew a distinction between Electronic Patient Records (EPR) and the Electronic Health Record (EHR). The term EPR is used for any electronic record containing patient data collected in a single organisation - e.g. the records held at the patient's GP - while the term EHR is used to describe a single centralised record which brings together a complete history of all the patient's healthcare "from cradle to grave" (paragraphs 2.10, 2.11).
Different 'levels' of EPR were also defined ranging from Level 1 (non-integrated departmental systems) to Level 6 offering clinical decision support together with multimedia records such as X-ray images (paragraph 2.64). The target was set of bringing all acute hospitals to Level 3 (integration of all clinical data within the organisation) by 2005 (paragraph 2.70).
This target was reiterated in "Building the Information Core - Implementing the NHS Plan" (NHS January 2001) which identified the goal of "a vibrant networked NHS ... with level 3 Electronic Patient Records and first generation Electronic Health Records [by 2005]" (p7).
In July 2002, the NHS published a draft specification of the systems which will provide the EHR under the title "Delivering 21st Century IT Support for the NHS - National Specification for Integrated Care Records Service" (ICRS). The new terminology reflects the long term aim of integrating healthcare and social care records into the same system to facilitate continuity of care when - for example - patients are discharged from hospital.
A shorter document issued on the same day (NHS, July 2002b) coined the term "National Programme for IT" (NPfIT) and outlined the strategy for this larger procurement of which the ICRS would form a part.
Two other NPfIT systems are also referenced below when describing changes to NHS processes. These are e-prescribing (electronic transfer of prescriptions to the pharmacist) and e-booking (now known as "Choose & Book") which allows consultant appointments to be booked online by primary health care practitioners such as GPs and opticians.
3.2 Electronic Record Development and Implementation Programme (ERDIP)
Between April 2000, and April 2003 the NHS trialled a number of approaches to implementation of EHR at District Health Authority level. The projects have been reviewed by independent consultant such as PA Consulting and their findings - which are very extensive - are available on CD-ROM and online (ERDIP, 2003). They give a good insight into the technical and organisational aspects of EHR and its potential within the NHS.
