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Summary Care Record launched in Bolton

Tags: CfH GP GPs Out-of-hours PCT Quality Scotland SCR Wales

24 Oct 2007

Summary Care Record in action

The first 48,500 summaries of patient records have been uploaded to the NHS Spine and out-of-hours staff in the Bolton pilot area will start using them over the next few weeks, Connecting for Health announced today.

Bolton in North-west England was the first primary care trust to take part in the NHS Care Records Service Early Adopter Programme. Final staff training is underway at the town’s out-of-hours service which deals with, on average, over 5,500 calls per month from patients who require access to a GP outside of their own surgery’s opening hours.

Connecting for Health (CfH) estimates that - with the current upload figure - around 900 calls per month could be from patients with NHS Summary Care Records (SCR).

Announcing the milestone in the NHS Summary Care Records programme, CfH said: “The records, which contain key medical information, including current medications, allergies and previous bad reactions to medication, have been uploaded from eight GP practices.

“This means that approximately 17% of the total Bolton population now has an NHS Summary Care Record. A further three practices are due to upload records in the next few weeks, with more to follow shortly afterwards. This staged approach has been adopted so that the PCT can carefully monitor progress every step of the way and ensure everything runs smoothly with the new system.”

CfH first launched the SCR at Bolton PCT in March and the PCT says it is excited to be moving forward in making the records available to out-of-hours staff.

Dr John Dean, the PCT’s medical director for quality and care improvement, said: “This exciting development will help us to deliver faster and safer care to our patients. Having accurate information on the patient’s medication and allergies is key to ensuring the right treatment. Staff are looking forward to having this information available for increasing numbers of the patients they see as more records are made available.”

But there is local scepticism about the exercise, too. A recent survey by the Bolton Local Medical Committee (LMC) was sent to all 169 GPs in the area, and from 98 responses, just 20 said they were in favour of proceeding with the SCR.

These results indicate that almost 70% of GPs working in Bolton are not in favour of the SCR being turned on.

Dr Chris Woods of the Bolton LMC told EHI Primary Care: “A significant number of doctors have reservations about the Summary Care Record. There are some serious concerns about the system, especially around the issues surrounding it connected with the nature of consent, confidentiality, cost and accuracy of data.

“I think there are some distinct reservations about the system which need to be settled, but it is only in pilot phase and we will have to see what comes of it. Perhaps it would be useful to have a local, or even national debate on the issue, as it is the cause of a great degree of controversy, not just in Bolton, but in England as a whole.”

Bolton has 57 GP practices and participation in the early adopter programme is not compulsory.

CfH say that eight practices have uploaded records, three more will follow soon and a further 23 practices have expressed an interest to become involved in the programme over the next few months.

NHS staff working in the out-of-hours service will only access the records of patients whose treatment they are directly involved in, and each time a record is accessed an audit trail will be created showing who accessed the information and when.

Initially, access to the SCRs will only be possible at key locations in the local area - A&E at the Royal Bolton Hospital, local out-of-hours services and the PCT’s walk-in centre.

The creation of SCRs for England runs parallel similar moves in Wales and Scotland. Scotland has the Emergency Care Summary which available to staff in emergency and unplanned care. Wales is developing the Individual Care Record, currently being piloted in Gwent, which is designed to assist clinicians working in OOH and emergency settings.

Links

NHS Care Records Service

Joe Fernandez

Reader's Comments

What is behind the resistance?

24 Oct 07 10:10

I'm scratching my head here over the survey results. I read earlier ehip articles about Bolton and am even more puzzled. Why wouldn't Bolton GPs want their colleagues in OOH to have clinically-relevant information?

My working thesis at this point is that they are afraid that this will eventually lead to increased scrutiny of their clinical practice by the NHS. The problem is that the NHS is currently massively inefficient compared to the best systems in the States and this is not sustainable going forward.

And the only way to increase efficiency while maintaining quality that has worked is to increase the use of information systems to share clinical information so that best practice can be discovered, propagated, and rewarded. This does mean increased scrutiny and comparison, but it ultimately leads to a healthier system and better clinical outcomes.

I can only conclude that Bolton GPs are taking a short-sighted parochial view and choosing to ignore the serious problems NHS is facing from an aging population, rather than embrace an approach which has been shown to be effective.

Bolton GPs right to be wary

24 Oct 07 15:10

Sharing records is one thing, and definitely to be applauded. But only if all confidentiality concerns have been addressed, and they haven't. The promised sealed envelope doesn't exist. Some people are not too happy about giving security services access to their medical records with no audit control. Local IG leads want to know what is going to be expected of them in the way of extra workload from the audit of those unathorised accesses that they are allowed to know about. Creating interoperability between existing systems to build a fuller picture makes sense, without creating a massive single database and having no control over what use this and future governments may make of that data.

re: What is behind the resistance?

24 Oct 07 16:10

I suggest the first poster adds the following to their working theses:

1. Rigorous data recording standards become vital once isolated 'codes' are plucked from medical records. Are these enforced in Bradford?

2. Beyond this a 'naked diagnosis' such as 'left ventricular failure' or 'depression' merely begs further questions - who determined the diagnosis, how, when etc.

3. Previous summaries are not available on the system: one can only view the last one sent.

4. The summaries contain "pseudo-SNOMED coded" data generated using a Read Version 2 to SNOMED map: this map has limitations. Amongst other things these codes will not be securely machine readable for decision support etc. even assuming there were any SNOMED enabled systems were out there to take advantage of them.

5. 'Legitimate relationships' to restrict who views these records remain on the drawing board

6. Patients can request that information be excluded arbitrarily from the summary : this is (in my opinion) merely a sop to silence critics of the lack of confidentiality. It places healthcare professionals in a position analagous to a bank being asked for a loan when the customer (may have) asked for their credit rating to be withheld. Opiate abusers for example will have a field day with this one. Other patients will exploit this feature for obtaining 'blind' second and third opinions from alternative care services. Worse yet, patients might withhold information that results in serious harm being done to them inadvertently by other providers.

Perhaps others can add a few extra caveats... but "short-sighted and parochial" these GPs ain't!

The only winner here is the Minister who gets to announce "NCRS has gone-live and is a blazing success, n million transactions per day, envy of the World .." cont. p94

Importing data from the GP SCR...

25 Oct 07 10:10

Will the GP SCR data will be in a suitable format to "import" into hospital computer systems on admission. If the hospital pharmacy system could import a patient's current/active medication (Drug product - Dose - Route - Frequency - Start date - Stop date) from the SCR this would save an enormous amount of time in obtaining a medicaton history (often from a tired and confused patient) on admission. Comments welcomed...

Resistance

25 Oct 07 17:10

I am an NHS information worker and, of course, a member of the public. There is a world of difference to me between making my records available to my local out-of-hours service and setting up a national database. I have instructed my GP not to allow my records to be uploaded to the national spine. I would be perfectly happy for appropriate records to be available to people caring for me. I just want to be in charge of it.

Importing data from the GP SCR...

georgebrown@bulldoghome.com

26 Oct 07 00:10

"....If the hospital pharmacy system could import a patient's current/active medication (Drug product - Dose - Route - Frequency - Start date - Stop date) from the SCR this would save an enormous amount of time in obtaining a medicaton history (often from a tired and confused patient) on admission. "

It should be noted that one often finds that the patient is often also taking over the counter and herbal remedies which should also be considered when making any medication related assessment. On sometimes those OTC and herbal remedies are the reason the patient find themselves in hospital in the first instance.

Status check ...

colin@clinformation.com

26 Oct 07 08:10

IMHO, whenever CfH issues another "good news" story it's always worth putting it into context so that we can understand what has really been achieved.

1. Four + years into NPfIT (which wasn't - of course - a green field programme) 1 in 1000 of the overall population are starting to be involved in a SCR pilot.

2. The principal impediments to personal health records (SCRs) well-documented 5 - 6 years ago during the NHSIA's ERDIP programme (and before) still remain to be addressed:

(a) The "difficult stuff" around confidentiality and access controls

(b) Meaningful professional and patient engagament in the development process (and that means much more than a CRDB and some clinical leads).

(c) Producing some robust empirical evidence (not just opinion and hearsay) that what is being offered by SCR will deliver benefits to the NHS that justify the costs involved. Addressing this question might go a long way to removing professional scepticism.

3. No huskies shot; plenty of fat ones around.

As a local pilot the Bolton experiment is fine - but it could and should have been done 3 - 4 years ago.

Importing data from GP SCR

26 Oct 07 12:10

It should be technically possible to import current medication data from the GP SCR into the hospital pharmacy system. The main hospital pharmacy system suppliers Ascribe, iSOFT and JAC would have to make their systems dm+d/dose syntax compliant to receive this data without rekeying. One point to consider is that hospital systems always include the medication route for each medication whereas GP systems don't. Maybe the GP system suppliers need to consider including this data element in future software releases.

Fields of brown

26 Oct 07 13:10

Colin is quite right that NPfIT isn't a greenfield project. As everyone knows, brownfield development is far more difficult and expensive, as you need to deal with all the stuff that's already there. Too often you have toxic waste to deal with.

But things are not that bleak. Mechanisms for access control have been established along with a working model for confidentiality (although the arguments will go on). Functionality for creating and uploading GP summaries is being put into GP systems. The evaluation of early adopters should deliver the empirical evidence the sceptics crave. Most important of all, and unlike ERDIP, the system is scalable to national level.

Getting all this in place has taken time. It is incorrect, and disingenuous to suggest that this could have been done three or four years ago.

Re: Fields of brown

colin@clinformation.com

26 Oct 07 15:10

Just to take a few of these points in turn:

1. What has had to be demolished (dismantled) in Bolton to allow this small-scale local pilot to occur (i.e. the "toxic waste")?

2. Mechanisms "established" - what does this mean? There's nothing on offer now that wasn't being discussed five years ago, yet there is still significant concern and little that resembles consensus amongst a range of interested parties about the current proposals.

3. Evaluation by early adopters will deliver the evidence. And will this be a transparent process?

4. The system is scalable to a national level. Really? The evidence so far from attempts at implementing local PAS systems through NPfIT suggests that SCR could be an insurmountable technical and organisational challenge. IMHO, seeing is believing on this one.

5. Getting "all this" in place has taken time. All what? This remains a small-scale local pilot of something that has been considerably scaled-down since the early work on SCR (then ICRS) back in the summer of 2003.

I find it disappointing that legitimate questioning - on the basis of a fair amount of evidence - of the time it's taking to make progress in this area is seen as disingenous. I'd also suggest that the "toxic waste" analogy speaks volumes about NPfIT's approach to existing systems: they are far from perfect but I - for one - am not convinced that there's anything better in the CfH pipeline.

More brown fields

26 Oct 07 16:10

Similarly, to take a few of these points in turn:

1. Toxic waste: yes, a bit colourful, but the point was a general one about legacy systems. GPs in Bolton have had to upgrade or replace their infrastructure and software to allow GP summaries to be created and uploaded. Not to mention improving data quality. Nationally, PDS and PSIS needed to be in place and supported, data migrated from legacy systems etc. A lot of non-trivial work there then.

2. Mechanisms: Ever heard of legitimate relationships and role based access? Registration athorities? Smart cards? Ringing any bells? Plus the time taken for the Ministerial Taskforce to set out the ground rules for consent... More non-trivial activity.

3. Evaluation: Who knows? I'd like to think so, given the pedegree of some of the people involved. There is justifiable concern that as with many government driven projects, deployment will happen whatever the outcome of evaluation.

4. Scalability: The comparison with PAS systems is not a valid one. This is a very different situation. Far smaller organisations (though more of them) using simpler systems. Prove that the process works with each type of GP system, then it should be a matter of logistics. Obviously, things are rarely that simple.

5. All of this: I was referring to the totality of the national and local infrastructure, software etc that is a prerequisite for the process to happen. I've mentioned some of it above, but it's important that people realise that this is not just something that's happening in Bolton, Bury and Dorset. They are all linked in with the major developments that have happened at national level.

Legitimate questioning is fine by me. Even better when it's informed.

Re: More brown fields

colin@clinformation.com

26 Oct 07 17:10

Actually ....

1. Toxic waste - I wasn't suggesting that the work was trivial; I was simply pointing out that it had taken far longer than expected to reach a stage where small-scale local piloting could take place.

2. All the technical approaches you mention were being actively discussed years ago. My point relates to the failure to achieve anything approaching agreement on their workability in the NHS.

3. Evaluation. Who knows indeed!

4. Scalability just a matter of logistics? I doubt that's true but I do believe you are correct in stating that the implications of rolling out SCR (as a system to support clinical care 24/7 across multiple organisations, professional groups etc) is very different from implementing PAS systems.

5. So what sort of IT programme sets up a vast supporting national infrastructure first (taking 4 years) and then goes on to evaluate (through a handful of small local implementations) whether a prime application (SCR) will work? Now where's that book on systems development models?

As your posts are anonymous I'm speculating that you may work within CfH or for one of its contractors or projects? And just for the record, I know of a lot of very well-informed people in health IT who currently work outside CfH and are - therefore - perhaps able to bring a more objective and wide-ranging perspective?

Take time out to enjoy one of the biggest milestones

27 Oct 07 02:10

So this sounds like a major milestone which should be celebrated, I did. Questioning is legitimate, but recognition and celbration of successes should be allowed too.

As I see it DH turned a political outline into a difficult proposition, CfH tried to procure something other than SPR, consultation led to a de-scoping, GPs are not happy (can someone perhaps research what GPs think a perfect NHS would be like, then we can know if should expect them to ever be content). GPs retain their gatekeeper role but have their presumption of data ownership challenged, and expose thier data quality. The adequacy of the SPR will become clear with time, no-one is forced to have a summary shared, and all the stuff to make this work has finally come together, bravo. Not quick, not cheap, but done! What is reassuring is that fellow contributors are thinking not so much about what should have been done better, but diving into how to actually share medication records - a good and particularly non-trivial successor to sharing of mere structured text. Respect to those who contributed to made this work, interestingly its not off the shelf, not an attempt to crush US software into UK shapes, but a bespoke scalable development, now we should be looking forward to the next bit whatever it turns out to be.

Milestones in context ...

colin@clinformation.com

28 Oct 07 15:10

The phrase "One of the biggest milestones" neatly captures the essence of my problem with yet another frenzy of NPfIT self-congratulation that the announcement of the launch of this small pilot scheme seems to have spawned. As I recall, the enjoyment of the "Nuffield goes live" celebrations was relatively short-lived so you'll perhaps forgive my caution. Not cheap, not quick: agreed. But - as a pilot - in what sense is it "done"? The answer, of course, is that this "bespoke scalable development" - far from being a major deliverable - is still very much under development, needs to demonstrate its technical and organisational scalability, as well as gaining acceptance with large sections of its potential user community (who were largely ignored in the initial specification of the DH's bespoke system).

As for not dwelling on what could have been done better (and by implication just carrying on regardless) some retrospection and learning is surely the mark of good IT programme management? At the very least there might be useful lessons to enable future pilots (and even large-scale implementations should they ever occur) to be achieved faster and at lower cost.

IMHO when the pilots are complete and the lessons are taken on board and incorporated into an agreed and achievable plan for wider national roll-out (including adequate funding), then - as the start of a meaningful implementation phase - that really would be a milestone worth celebrating!

Toxic waste II

29 Oct 07 11:10

In my view, the toxic wasteland has been the opportunities lost by 5 years of failed NPfIT delivery, and whilst this is still being forced forwards, I don't believe quality will ensue.

A successful Summary Care Record could link individual EPRs without having to sweep away all the existing working systems, many of which still offer far better value and features suited to UK practice and administration than the LSP offerings.

But the record on system performance (especially speed, but also system unavailability) for Choose and Book, ETP, and LSP solutions do not bode well.

Has the turbo-charger been switched on ?