GPs face limits on third party add-ons

Tags: Choice EMIS Google GP GPs Mobile phone PCT PCTs

07 Oct 2008

GPs in some parts of England claim they are facing unworkable restrictions on the kind of third party IT they can use in their practices under the GP Systems of Choice PCT-practice agreement.

The PCT-practice agreement states that practices must get the PCT’s permission to use additional hardware or software. It also says that if hardware or software is installed without PCT approval the practice will be responsible for the costs of any subsequent problems.

However Dr Charlie Stuart-Buttle, chairman of the EMIS National User Group, said he had been approached by several GPs facing problems over what was allowable.

He told EHI Primary Care: “PCTs seem to be taking different approaches in different areas. Some of them are quite laidback but others are coming up with quite long lists of what they are banning.”

Dr Alan Ferris, a GP in Hertfordshire, claims the list of acceptable hardware and software from his PCT is unnecessarily restrictive.

He said: “The reason given for much of the banned software is that it ‘compromises support with the IT support organisation’ which seems outrageous to me. Either the IT organisation is there to support general practice or the new meaning of ‘support’ is now ‘dictate to’.

Dr Ferris said the restrictions included use of Google and Yahoo toolbars and the Firefox browser.

He added: “It also means that in my case I can’t use Nokia’s software to synchronise the calendar on Outlook with my mobile phone and nor can I go out and buy a digital camera to take clinical pictures.”

Dr Stuart-Buttle said the lists of acceptable software and hardware were negotiable and that practices should go back and talk to their PCTs, preferably with the support of their LMC.

He added: “For PCTs to give the reason that this will make more work for us is nonsense. They key word in service level agreement is service and PCTs should be providing a service to practices.”

Guidance on the PCT-practice agreement issued by Connecting for Health and backed by the GPC states that PCTs are expected to act reasonably and take account of the list of third party software approved by the GP clinical IT system supplier when they make decisions.

Fiona Barr

Reader's Comments

Redefined support

07 Oct 08 19:10

Yet another example of primary care being bullied into submission, rather than properly supported to carry out their role as independent contractors. This should be taken up by LMCs and the RCGP on their behalf.

Control is good

mick.smith@nhs.net

08 Oct 08 08:10

As an IT manager for 2 large practices I to think it is restrictive, but I can see the reasons for these restrictions. I think the PCT comment reported above is unfortunate. We are constantly complaining that our network performance is going down hill and there are no surprises when systems crash for no aparent reason. And I think this is really the whole point of this element of control at last, we cant keep adding untested software to a clinical network and just expect everything to be ok. Even PCT controlled trials of software throw up unexpected problems. We can still request technical approval and in return expect a formal software/ hardware trial process before unleashing it on our clinical networks. It make take longer but surely its worth the peace of mind that you've done everything you can to keep your network safe.

Where has common sense gone?

08 Oct 08 12:10

The whole point is that PCTs are expected to act reasonably. That means actually assessing what practices need to carry out their day to day business, including their financial needs, not just clinical care. Only when that assessment has been done for each practice (they are all entitled to an annual review) can it be deemed the PCT has acted reasonably.

It should take note of existing approvals, such as remote access already approved by other PCTs, Firefox is proven not to affect CfH or clinical systems. Understand the way practices need to work, and build a good relationship with them. Then if you have to restrict something because it has proven difficulties, they will understand.

Issuing a blanket ban, ignoring GP's needs, will only have a negative effect on PCT/practice relations which will benefit no one. I pity that particular area of the Country, others locally have been much more reasonable.

Control is also good for patients ..

08 Oct 08 13:10

So Dr Ferris would like to load his appointments onto his mobile phone and take 'clinical photos' on his digital camera - which he, presumably then wants to load into his practice system. How much information do these appointments contain - patient names? Conditions? Symptoms? And which parts of his patients' anatomies might appear?

Speaking as a patient, if my GP were to want to do these things, I would very much hope my local PCT had enough control to ensure this could not possibly happen UNTIL and UNLESS they were absolutely sure about the security of data going out of the systems: about the safety of devices loading data into the systems: about the confidentiality and security of data while it is on remote devices .... etc, need I go on?

Data

08 Oct 08 17:10

Dr Ferris doesn't want to load his SURGERY appointments onto his phone, he just wants to synchronise his phone with Outlook, as I synchronise Outlook with my PDA. My Outlook calender just says I have surgery from 08:30 - 12:00, it doesn't list the patients that I'm seeing (who on earth wants that on their phone/pda?).

The photos that he wishes to take - with the permission of his patients - will be attached to their record and stored in their personal record on his practice server, in exactly the same way as a scanned hospital letter would. How useful storing pictures are is another matter (presumably very much so if he had an interest in dermatology).

Non-clinical diaries

julian.spinks@nhs.net

08 Oct 08 22:10

I, like Dr Ferris, have a phone with an appointment diary which I use. However it is not patient appointments that are transferred. There would be little point in doing this as they are only relevant when in the practice and my phone would not cope with the 80+ appointments per day. It is the non-clinical, business appointments including PCT meetings, practice events and personal events that I need to transfer. This is no different from the use of most PDAs in a business setting. If I am unable to use the software for my phone this would seriously affect my ability to run my practice (and my life).

Likewise I have a digital camera which is used for clinical pictures and a digital microscope for saving dermatology pictures. neither leave the practice and are used to save direct to the clinical system. This requires software. Without their use I would not be able to monitor changes in suspicious moles or send pictures to the dermatologists.

I understand the need to prevent harm to systems but restrictions must take into account legitimate needs of practices.

Last sentence says it all

09 Oct 08 10:10

Julian Spinks has it exactly right. No GP would willingly risk compromising his system, it is mission critical. Something IT helpdesks sometimes don't understand! The software GPs load is what they need to run their businesses and to increase the functionality of their clinical systems to benefit patient care. PCT IT departments do not have the necessary understanding of what those needs are, which is why each practice needs to discuss these under the yearly review. PCTs should not be asking practices to sign up before this has taken place. Under information governance rules, each practice has a responsbility to do their own risk assessment, and this is done before loading software. No practice should, or would expect free support from the PCT for these extras they need to do the job, that is understood. In the unlikely event that something loaded did cause a problem, they would uninstall it and sort out any disruption themselves.

There is a world of difference between 'support' which is in the GMS contract, and 'control' which isn't.

Re The Last Sentence .....

09 Oct 08 13:10

While I agree whole heartedly with most of what you and Dr Spinks say .. there are limits and not all GPs are competent in matters IT and understand fully what the potential implications are for an installation (neither might I add do the PCTs and their IT providers) Google and Yahoo tool bars are mentioned .... both totally frivolous items .... both record your exact search strings .. both communicate with external data bases.. Can you be sure that these data bases are secure that searches for pulmonary & diverticular diseases are not linked to an IP address enabling a hacker to put 2 & 2 together and begin an assault on your fire wall?

I don't know the answer ... more importantly do you?

Re the last sentence

helenwilkinsonmakey@fastmail.fm

09 Oct 08 14:10

The last sentence refers to firefox and yahoo storing details and linking them to an IP address. The exact same thing can be said of Microsoft and Internet Explorer the browser. PCT's push Microsoft who is to say that are not storing details and linking IP addresses? Personally I would trust Mozilla and Firefox over Microsoft and Internet Explorer. At least Mozilla code is open source and freely available for anyone to examine and see what data they are planning on storing and linking, if any. Whereas Microsoft and Internet Explorer are completely closed source one does n't have a clue what they are up to!

Where is the consultation?

09 Oct 08 14:10

That is just the point, you have no evidence of harm, but want to ban it just on the offchance, though you can't specify what that harm might be. You are not content to abide by the practices' own risk assessments. What would have been useful would have been for CfH to have drawn up a list of approved software as a starter for ten, and just left practices and PCTs to negotiate any other local needs.

To take one example, Firefox is approved by CfH and their applications tested against it http://www.connectingforhealth.nhs.uk/newsroom/news-stories/online-booking/ If it is good enough for CfH, then I do not feel it is up to a PCT IT department to ban it without any concrete evidence of harm to back it up.

What is at issue here is not so much the list of items, there should indeed be some effectively blacklisted if proven to cause trouble, but the lack of any willingness to attempt to understand how general practice works, and consult with the practices to draw up a reasonable list which they are happy with. Why have PCTs completely ignored the instructions in the contract to consult? - and I mean properly consult, not the sort of 'meet us and we'll tell you what we are going to do' which is sadly all too common.

Dr Ferris is a busy man...

09 Oct 08 23:10

... and needs an electronic diary to know when he's doing a hospital clinic, a GP surgery or collecting a child from somewhere. Unless you are interested in my son's first name, you won't find any identifiable data in my Outlook calendar.

I'm actually more aware of patient confidentiality than many at the PCT, and have been into battle on that front more than once.

The clinical pictures not only are anonymised, but I also have the patient's written consent for these to be used for teaching purposes.

We are all perfect - so why is the system so slow

14 Oct 08 22:10

Sorry guys. I work in a PCT supporting GPs. We had a practice which complained of a slow network connection. After a lot of investigation we found that one of the key bandwidth hoggers was that they were streaming Internet radio to the waiting room. "To maintain confidentiality for the patient talking to the receptionist". The IT manager offered to go and buy them a Radio.

There are other examples we have seen where lots of add-on programs and internet browsing resulted in very slow operation of Choose and Book. A similar, but clean machine in the same practice operated very significantly faster.

Not every partner, secretary or receptionist in every practice understands the linkages between these things, just as I can't diagnose clinical conditions. Please give us some credit.

The PCT should be able to justify why a restriction is in place, it would have been easier perhaps if the list were centrally agreed, but it is dynamic, and often determining which add-on, or seemingly innocuous, but unfamiliar program is causing an intermittent problem can consume enormous support time. And when new versions of clinical or CfH software are issued, suddenly new problems emerge.

There are three words in Service Level Agreement. All of them are significant. Is it more important that you can access clinical records efficiently, or that you have freedom to jam up your system ? PCT IT teams have limited time and budgets, and cover a large geography and very varied infrastructure. Bringing at least some consistency and order to it will help you to practice medicine efficiently.

And the potential for malware or trojan attack to compromise security of your patient's data is much greater where lots of great programs have been downloaded 'to see what they do'.

Having also worked with Mental Health Trusts where every feature is locked down unless explicitly allowed, these restrictions are tame.

We need common sense and collaboration from all parties. Negotiate, but be prepared to justify what you really need.

re "We are all perfect - so why is the system so slow"

alan.ferris@gp-e82027.nhs.uk

15 Oct 08 20:10

Thanks for your anonymous comment.

Similar logic would clear the roads of all traffic after the first drink-drive accident.

Not every GP or practice staff member is an idiot either - perhaps the giving of credit should be a 2-way thing?

Not unforseen (except by the GPC?)

richard.james@falmouthhc.cornwall.nhs.uk

16 Oct 08 13:10

The Practice PCT agreement was bound to lead to these conflicts and it is totally beyond me why the GPC agreed to it. However the agreement is only that, it is not legally enforcable and being imposed it is not even an agreement. On the other hand GP practices are conducting legitimate businesses and are entitled to conduct their business without unreasonable impediment from PCT IT departments. PCT IT departments are obliged to support GP IT, not hamstring it as reports suggest is happening and practices should be assertive about this. We do still have to take responsibility for the IT we use, as we always have and especially if not supported by the PCT, but this agreement is not in place purely for the benefit of PCT IT departments and they must not be allowed to dictate how we go about our business or we shall all soon be in the mess secondary care is in.

Firefox

17 Oct 08 11:10

'To take one example, Firefox is approved by CfH and their applications tested against it' - Firefox is only compatible for accessing the Patient side of CaB, not actually CaB itself. Another GP jumping on the mock CfH bandwagon, shouldn't you be prescibing paracetamol to someone?

Firefox included in NHSMail training

21 Oct 08 11:10

If CfH want to discourage the use of Firefox, then why is it included in their online NHSMail training?

Unless a PCT can come up with specific proof that using Firefox will damage the other applications used for patient care, there is no reason to ban its use.

If Paracetamol were to be invented today, it would be banned because of the dangers of liver damage, but it happens to be an essential part of treatment, there is a balance in everything.