GP systems market shake-out predicted by Granger

1

GP Systems

12 Jul 05 20:07

Since in my practice recording clinical data from 1992, alll consultations being on computer, coded with free text added to make the record complete I find it difficult to understand how it can be said our GP system could do better. Can he give evidence how hospitals have been able to provide a better clinical record ?

As an EMIS user I consider myself fortunate that the system isn't built on a business model but a clinical model, I'm sure users of other systems feel similarly.

Data transfer between syssten is already suspect. We'd love to get electronic dischrge etc, and are a pilot for C&B, But after about 12 BT visits no N3. Getting to the stage where you can use C&B takes over 5 minutes ! Don't blame GP's for not using an inadequate service.

We have concerns on privacy etc. But you have got to show a useable system if you wish us to use it. As for decade old technology. Seems like the NHS is working to those standards.

Give me a better system than I have now, which provides better care & I'll use it. Until then I think people will want to hang on to such archaic, useless systems such as EMIS, Vision etc.

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2

Granger please explain

gerard@careprovider.com

12 Jul 05 21:07

Can Mr Granger explain, and give some evidence for the statement that "significant data corruption has occurred". Medical data is not immutable and depends more on the user putting it in. There has to be a compromise is getting useful data in to help manage patients quickly, usually during the consultation, than demanding some absolute data standard. It?s not that easy. What does he mean data corruption and hidden by suppliers? Can e-health as for evidence of this statement please for us users? Which firms? When? How, What? We must be told. Is he implying patients have been put at risk and this corruption hidden?

Also what does he mean by G.P. suppliers using decade old technology. Which firms? SQL and PHP for example do not strike me as old technology that runs in the background of Microtest?s software for example. Some interfaces may look old but they are designed over years of GP input to be ergonomic rather than pretty.

As for CAB (Choose and Book), G.P.s for years have been willing and able to send data up by email for appointments for years.?. it is the hospitals that could not cope with that. CAB is fine but it is the choose bit that is the problem for G.P.s and the clerical booking functions of booking are being transferred from hospital to G .P.s? surgeries without the staff funding coming with the transfer. £95M promised is being spent on hardware not GP staff.

Gerry Bulger www.careprovider.com

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3

Get real, Mr Granger

phil.griffin@nhs.net

13 Jul 05 09:07

The comments reported here reveal either a visionary assessment of how GP IT will develop, or a crass lack of understanding of how GPs consult and record information. I fear the latter. "Free and unstructured text" is a crucial part of my record keeping.

Coding problems is equally crucial - the two sit together. Recording verbatim things patients say is an essential way of keeping the "flavour" of the consultation, and I would expect a complete lack of enthusiasm from most GPs if we are expected to use systems that cannot do that. Most of our work is unstructurable - something you learn very quickly when moving from the medical student history-exam-investigations-diagnosis-treatment model to GP SOAP records.

Mr Granger should remember - we have no contractual obligation to use national systems, and we have a contractual right to use a system of our choice. He should also remember that we have the data the National applications need. If he expects us to change to a less useable system that's too structured for GPs patient's needs, then he needs to rethink. I, and many of my GP colleagues, are willing and ready to co-operate and move forward into an interconnected world for the benefit of patient care, but I will not be bulldozed. Come and see me Mr Granger and I'll show you the real world.

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4

A Detailed Response

ewan@woodcote-consulting.com

13 Jul 05 23:07

>Paragraphs starting ">" are my comments others are from the original report

The numbers of GP system suppliers and local pharmacies could be reduced within five years as the NHS IT programme transforms their markets, Richard Granger, chief executive of NHS Connecting for Health, has predicted.

>One has to be careful responding to a press report, but having been to a few meetings where Richard Granger has shared his views and trusting as I do the professionalism of eHealth Insider I’ll take the report as accurate.

>The whole tone indicates a view that GPs and their current suppliers are the problem and exposes a worrying lack of understanding of some of the issues.

>GP are a cussed lot and have kicked up a fuss about every proposed change from and including the founding of the NHS. However, paradoxically GPs have been major innovators and have embraced change wholeheartedly once they have been persuaded of the benefits. This is true of the contribution of GPs to health care as a whole, to family medicine and to primary care informatics. GP have encouraged IT system suppliers in their image who are also cussed, but highly innovate and together they have placed UK general practice at the forefront of health care IT globally.

>CfH has made significant progress in getting GP engagement. GPs could and should spearhead the application of IT across the rest of the NHS, but this process is not helped by some of the statements reported here.

Granger described the primary care systems market as "immature" and based on a business model unlikely to be sustainable. He said: "I don't think that most of the GPs' system suppliers are going to exist in five years' time, as I don't think it's a sustainable business model."

>Whether or not current suppliers will exist in 5 years times will depend on two factors:

>Firstly, the willingness of the NHS to allow GPs to continue to use systems that best meet their needs and those of their patients. CfH can kill the current suppliers if it wishes to so, but the Government will need to be able to justify any such action to the electorate. It seems to me that currently CfH understanding of existing systems is “immature” and there support for GP choice at best grudging.

>Secondly, the willingness of existing suppliers to develop their systems to meet changing needs and to integrate with the Vision of CfH. It seems to me that their delivery of QMAS, much trumpeted by Mr Granger, and their support for C&B, ETP and GP-GP demonstrates a willingness to do so.

>We certainly need a new generation of systems to meet the future needs of GPs as part of a connected NHS. Whether these new systems will evolve from the existing market leaders or be created for the NPfIT remains to be seen. My view is that the public interest is best served by allowing the two camps to compete on a level playing field with those that demonstrate that they can meet the needs of GP and the vision of CfH best being taken forward. As none of the “new systems” have yet implemented any GP functionality on the ground it is far to easy to write the existing systems off.

New systems might not be popular but they will be safer, added Granger. Existing user interfaces were liked but, he argued, in many ways they were dangerous, because they can allow free and unstructured text to be entered as records. "A better structured system is actually less usable," commented Granger.

>We have the knowledge to make both old and new systems safer, much of it held by the existing suppliers. There is no basis to assert that the new systems produced for the NPfIT will be safer than future version of current systems.

>An EPR that does not allow free text to be included within a structured and coded record (which is what existing systems do) will not provide a basis on which safe or adequate patient records can be built and will not meet the needs of GPs or any other clinician trying to work without duplicate paper records.

>The old systems are popular because they are fit-for-purposes and work predictably (if not always reliably). When new systems are available that are also fit-for-purpose and which demonstrate benefits which justify the cost (in the broadest sense) of moving GP can be expect to embrace them.

>If Mr Granger really said "A better structured system is actually less usable" he needs to think again. The achievable aim is systems that are both well structured and highly usable.

He went on to state that existing primary care suppliers have deliberately covered up "significant" data corruption of electronic patient records.

>There have been many examples of "significant" data corruption resulting from many factors (roughly in order from the most common to rarest): Data conversions between systems, hardware failures, systems upgrades, user tampering and software faults. It would be true to say that GP suppliers have not trumpeted these from the mountain top, but is grossly unfair to suggest that they have tried to cover up problems. My experience as an erstwhile supplier is that we and others always made our customers aware whenever we became aware of matters that might have corrupted data and thus put patients at risk and applied all our resources to correcting problems. Not least because our insurance cover was only good if we did.

Granger said that large numbers of records were sat on decade-old technology and that "significant data corruption" had occurred, some of which had been covered up by suppliers.

>For “decade-old technology” one might read “mature, proven and well-understood technology” (and some of it is at least two decades old) The “old” components are predominately the computer languages and database systems at the core of many existing systems and these run reliably and amazingly fast on the modern hardware on which they typical operate (having been written for systems with 1/1000 the processing power applied today - albeit slowed down somewhat by bloated modern operating systems). However, much new technology has been applied to work alongside and slowly replace these venerable components.

Asked about system choice, Granger said that it "makes life more complicated" for technical implementation, but at least made it easier to persuade GPs to adopt the new systems.

>What GPs are being offered so far is existing systems delivered out of LSP data centres rather the practice back office. This is a best a small step towards the vision of CfH and probably a detour. System choice just postpones the need for CfH to persuade GPs to move to systems based on a shared record across a health community; this is a welcome respite, but no more.

Turning to the community pharmacy sector the NHS director general said the implementation of electronic transfer of prescriptions will cause bricks-and-mortar pharmacies to suffer financially and may result in closures: "Making things available electronically means moving to virtual pharmacies, with all the social and economic impact that will cause."

Comparing the pharmacies' situation to sub post offices that have had to close due to benefits being paid into accounts electronically, he said: "Unless we get services into these industries, you are going to get [reduced] footfall, no cash flow and the whole business model will fall apart. I don't think those things have been thought through fully yet."

>Mr Granger is being far too apocalyptic. ETP will facilitate mail order pharmacy and the automated central assembly of repeat scripts (for distribution by mail order or back through local pharmacies). Co-located health centre pharmacies are likely to lose business to those more conveniently located in relation to patient’s normal day-to-day movements (as geography becomes history as far as script collection is concerned). The US experience (where the patient’s have a substantial financial incentive to use mail order) has been that there is a ceiling for mail order demand at about 15-20% UK market estimates are that mail order might take 3% – 5% (I think these are low) but in either case with the annual growth in script volume running at over 10% the worst bricks and mortar pharmacies can expect is to see a reduced growth in business.

>Mr Granger is right that Pharmacies need to embrace the opportunity to deliver new professional services provided by the new Pharmacy Contract, but pharmacy and the DoH need to agree the way forward and the IT support that is required before CfH can do much to deliver it.

The NHS IT director general's candid remarks came in a speech and question and answer session at last week's Health and Social Care Exchange conference in London, as Granger spoke of the wider implications of NHS IT modernisation programme.

Turning to Choose and Book Granger asked GPs who did not want to spend consultation time doing electronic referrals for some give and take.

>There are three processes here.

>1) The professional information exchange of the referral. GPs already do this electronically, by letter, via a myriad of forms, and are often supported by some automation provided by existing systems. GPs would love to make all referrals using a well thought-out electronic system, which should save them time.

>2) Choosing. GP already try to refer patients to services that best meet the patients need and are willing to discuss options to some extent. GPs would like to be the patients advocate in choosing the best service but unfortunately don’t have the time or information needed to support a useful dialogue. They do not want be drawn in to conversations about the relative degree of car-park congestion at various hospital or into trying to interpret complex and often meaningless performance data. Particularly when the patient just wants to go to the local hospital where their family have always gone.

>Booking. Currently GPs don’t get involved in this so any involvement no matter how good the electronic systems mean more work for them of their staff. The current system of booking is awful for patients and leads to unnecessary waste and a good electronic system is to be welcomed. However, GPs themselves can’t afford the time to be involved (and no one would wish them to become booking clerks) and if practice staff are to do the work practices need to be paid for this. With the £95 million in incentives for C&B being grabbed by PCTs it is hardly surprising that GPs are unenthusiastic.

>C&B has given itself problems by confusing and combining these processes. However, things are slowly improving and C&B might just become attractive to GPs if it continues to listen to the feedback it is getting. This is not the time to accuse GPs of being unwilling to provide some “give and take”

"In a GP's practice, a lot of things are electronic, but the discharge summary isn't... GPs frequently tell me they want discharge summaries fired into their systems but they don't want to do the referral. If you don't do the first bit, how can you expect your clinical colleagues to give you the other bit back?"

"As we move to longitudinal healthcare records there will have to be some give and take in the allocations of professionals' time," he added.

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5

A secondary (care) view

14 Jul 05 13:07

As I am not a GP, maybe I'm not qualified to comment. However, I do that find Mr Graingers comments smack more of trying to justify trying to push unwanted systems onto GP's, bypassing the promise made that GP's should have a choice of systems.

As a patient, I wouldn't like to think that my GP would say "sorry Mr X, I cannot make a note of the fact that you are depressed due to your partner suffering from terminal illness and you cannot cope anymore, I don't have a Read code for it"!. A bit of an extreeme example I know, but you get the point. I want my GP to make a note of whatever I tell him/her, otherwise, what's the point in seeking their advice in the first place?

As far as the Immediate discharge summary goes, I am just beginning a project to send the IDS, electronically, from our hospital EPR to GP's clinical systems (and it will read code AND file into the patient's record AND notify the GP of it's arrival). To be honest, I don't give a monkeys when or how the GP's will embrace choose and book. It is better when health communities work together, but I don't think it's as simple as "you send them yours and they'll send you their's"