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This means that successful implementation of health IT requires the initial and sustained engagement of front-line users of the technology, whether it is healthcare professionals or patients. Even with all of the background wisdom born of prior experiences in the UK and elsewhere, the chances of getting it perfectly right at the start are low. It concerned us that many of the discussions we heard from national IT and health policy leaders regarding health IT referenced financial returns, perhaps because the arguments for public monies need to be framed this way, and because public resources are currently so scarce (in 2012 only a handful of English hospitals ran deficits; in 2016 the vast majority do) (7). The key components of NPfIT are listed in Table 2: Key components of NPfIT (10). Privacy is very important, but it is easy for privacy and confidentiality concerns to hinder data sharing that is desirable for patient care and research. Instead, digitisation is an essential tool for meeting the needs of patients, their families, healthcare professionals, and the entire nation – in short, to improve the way care is delivered in the NHS. Although the negotiation of LSP contracts centrally is said to have saved an estimated £4.5 billion for the NHS, it came at a heavy price in intangibles, especially the goodwill that had previously characterised the relationship between IT suppliers and the NHS. For our purposes, we highlight the latter category, which includes a description of the importance and current inadequacy of the clinician-informatics workforce[footnote 17]. Digitisation should also be an enabler of better health, by creating new methods to follow populations of patients, to engage them in their own care and wellness, and to promote preventive services and public health interventions. Moreover, the workforce of clinician and non-clinician informaticians, informatics researchers, programme evaluators, and system optimisers needs to be increased and nurtured. Drs. Benson T. Why general practitioners use computers and hospital doctors do not–Part 1: incentives. Once a trust has chosen a supplier, in addition to general help with contracting, implementation and optimisation, it may need advice on how to work with that supplier and its product. The problems with the implementation of the care.data programme – which lacked a comprehensive communication strategy to engage with the public and a clear protocol regarding who could access the data – illustrate how sensitive these issues are. There are several reasons for this. In such cases, the threat of penalties or press coverage that make the problems appear scandalous can lead organisations that are considering digitisation to think again. Bijali Construction. In January 2009, the government’s Public Accounts Committee criticised NPfIT, noting that costs were escalating without evidence of benefits. One important area relates to contracts with suppliers. As one national IT leader told our group, ’Never give money out faster than it can be absorbed.’. These are central hubs (usually non-profit organisations created for this purpose, sometimes run by an existing entity such as a hospital association) that mostly depend on fees from users, though there has also been federal and foundation support for HIEs. In 1989, the DH introduced a scheme for direct reimbursement of hardware and software costs associated with the implementation of accredited systems in GP practices, which further increased adoption (18). The US was well served by several decades of research into information technology and a strong cadre of clinician-leaders in IT, many of whom became chief medical/nursing/pharmacy information officers (the equivalent of UK CCIOs and CNIOs). (One problem with the SCR is that its content is completely controlled by the GP, whereas a truly interoperable clinical exchange needs to be modifiable by different clinicians in different clinical settings.) The overarching strategy established by the Five Year Forward View, the more digitally-focused goals and framework created by the NIB, and the allocation of significant resources to support digitisation by the Treasury all set the stage for the current effort, and for this report. The Advisory Group estimates that an average-sized trust needs at least 5 such individuals on staff. (Interestingly, in light of growing rates of burnout among healthcare professionals, there is a new movement to add a fourth aim: professional satisfaction, a point we’ll return to later (3)). The ambitious National Programme for Information Technology (NPfIT), designed to digitise hospitals and trusts, was launched in 2002, only to be shut down 9 years later (5). In The Digital Doctor, a case is described in which the lack of user-centered design, along with alert fatigue and overreliance on technology, resulted in a 39-fold overdose of a common antibiotic (33). The problem lies partly in poor design, and partly in the fact that EHRs have become enablers for third parties who wish to ask doctors and nurses to document additional pieces of information (for billing, quality measurement, etc. The proposed Phase 2 national funding will be needed to support this group’s digitisation in 2020 to 2023. However, part of the challenge in constructing a new policy approach to digitisation is that NPfIT’s history creates a sizable, and perhaps unfair, bias against centralised approaches. We agree. Of course, computerisation is not new to the NHS and its associated primary care practices. One theoretical example, Lawrence said, would be an older woman who visits her GP, and is told to have a battery of tests. One key obstacle to information exchange and interoperability in the US: a regulation dating back to the 1990s that makes it illegal for the government to create a universal patient identifier. If Lawrence has any advice to dispense to other regions seeking to build a fully integrated system, it is this: Don’t rush. It has long been recognised that the use of computers during consultations can adversely affect GP-patient communications, but there has also been evidence that UK patients accept the role of computers and do not feel that they lead to loss of ‘the personal touch’ (32). Schiff GD, Amato MG, Eguale T, et al. After extensive consultations, an interdisciplinary group of experts – including in informatics, policy, interoperability, usability, clinical practice, workforce, and the patient perspective – was convened. In order for a clinical information system to be successfully implemented, there needs to be a robust and reliable network, ubiquitous wifi, plentiful and functioning computer terminals, and brisk sign-on. These trusts are likely to develop important innovations, to inspire other trusts to digitise, and to help anchor local health IT learning networks (recommendation 8: Organise digital learning networks to support implementation and improvement). “To get there you do need to be willing to take every opportunity, because if you will not be doing it, somebody else will. We are grateful to the leadership of the Department of Health and the National Health Service, particularly Secretary of State for Health Jeremy Hunt and NHS England CEO Simon Stevens. This has resulted in an intimate understanding of GP requirements and has produced systems that do what GPs need them to do. The Centre can do everything from booking transportation to ordering equipment. Bouamrane MM, Mair FS. Since 2015, GPSoC-accredited systems have been required to allow patients to view their electronic records, although some practices have not actively promoted this feature (27). In part informed by its analysis of the US experience with HITECH, NIB leaders chose to emphasise interoperability, rather than just adoption, of health IT. Core content for the subspecialty of clinical informatics. These national applications were: Central to the Programme was the creation of a fully integrated electronic records system designed to reduce reliance on paper files, make accurate patient records available at all times, and enable the rapid transmission of information between different parts of the NHS. We know the National Data Guardian review grappled with these issues and we support her committee’s recently reported findings and recommendations. ↩, We were pleased to learn that, in response to our recommendations, on 7 July 2016 NHS England and NHS Improvement announced the appointment of Prof. Keith McNeil, a seasoned healthcare administrator and former transplant specialist, as the first NHS Chief Clinical Information Officer, supported by Will Smart in the role of NHS CIO. The goals of interoperability are not merely to create the technical capability to exchange digital data. Epub 2015 Apr 15. Koppel R, Lehmann CU. J Patient Saf 2011 Dec;7(4):169-74 etc. In fact, it is one of the most complex adaptive changes in the history of healthcare, and perhaps of any industry. All content is available under the Open Government Licence v3.0, except where otherwise stated, Read about the arrangements following The Duke of Edinburgh’s death, Using information technology to improve the NHS, 3: The National Advisory Group’s methods, Appendix A: Terms of Reference (Department of Health, February 2016), Appendix B: Meetings held by Chair and/or Advisory Group, Appendix C: Summary of timetable for deliverables related to key recommendations, Appendix D: Milestones in digitising the NHS, nationalarchives.gov.uk/doc/open-government-licence/version/3, recommendation 6: While some trusts may need time to prepare to go digital, all trusts should be largely digitised by 2023, section 3: The National Advisory Group’s methods, The National Programme for information technology, The US experience with health IT, with possible lessons for the, finding 7: Health IT Systems must embrace user-centered design, recommendation 3: Develop a workforce of trained clinician-informaticians at the trusts, and give them appropriate resources and authority, recommendation 7: Link national funding to a viable local implementation/improvement plan, It is better to get digitisation right than to do it quickly, recommendation 8: Organise digital learning networks to support implementation and improvement, recommendation 2: Appoint and give appropriate authority to a national, Personalised Health and Care: A Framework for Action 2020, Programme assessment review of the National Programme for IT, The dismantled National Programme for IT in the, More than 1 billion prescription items dispensed in a year - or 1,900 a minute. The GP2GP service enables the transfer of entire electronic records between practices, even when they are using different EHRs. And I'm not a steward. This deficit, along with a general lack of workforce capacity amongst both clinician and non-clinician informatics professionals, needs to be remedied. While nearly two-thirds had been clinicians for more than 20 years, less than 20% had been in their CCIO roles for more than 5 years. All of these issues – technical, economic, legal, political – need to be addressed in order to create a functioning interoperable system. Health Education England, in collaboration with the Royal Colleges and other relevant bodies, should develop and begin to implement a plan to raise the level of digital education in all health professional educational settings, including medical, nursing and pharmacy schools, and in continuing education settings for practicing healthcare professionals. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. But in February 2016, Secretary of State for Health Jeremy Hunt announced that the Treasury had allocated £4.2 billion over the next several years in support of the NIB framework (51). More rigorous health information exchange (, Improving quality, safety and efficiency, leading to improved health outcomes. But it is an argument for keeping sight of the ultimate goals of improved health, better healthcare, and lower costs; for being prepared for unexpected consequences; for creating a system that is nimble and able to adapt over time; and for retaining a relatively long-time horizon. Sci Transl Med 2010; 2:57cm29. This should be addressed on a case-by-case basis. GP computer systems have evolved greatly over the last 40 years. Second, the health IT workforce (both clinician-informatics experts and non-clinician health technology experts), which was never very robust to begin with, has been dangerously thinned. I think we’ve lost them. Ms. Hafner and other staff members were compensated for their work. ‘This is a huge system change, and it takes time’. A bin 2-savvy display would provide the functionality a provider needs to accomplish tasks with a reduced cognitive load. Lab investigations conducted by other providers are readily accessible by GPs. Therefore, all of them should receive foundational training in informatics, and – probably more importantly – in the integration of digital tools into their practices (6). They include: The government remains highly supportive of GP digitisation. 2014 Nov-Dec;12(6):573-6. doi: 10.1370/afm.1713. Regarding the workforce, while crucial usability work must be performed by EHR developers, every product needs to be customised by the hospital or practice that implements it. It should not be assumed that a new national strategy to digitise the secondary care sector is without risk simply because it differs from NPfIT in leadership or structure. In high-risk industries like healthcare, usability is inextricably tied to safety. Rather, we would emphasise making usability information – perhaps collected by third parties – available to trusts to guide their purchasing decisions. While patient safety is non-negotiable, regulators and commissioners need to have a degree of tolerance for short-term slow downs and unanticipated consequences in the period following electronic health record (EHR) implementation. About 10 million patients in the US have full access to their clinician notes (‘OpenNotes’). This will involve a major effort by existing professional bodies such as the Royal Colleges, the General Medical Council, and the British Computer Society to create and certify training programmes for clinician-informaticians. Patient access to self management tools. Six years later, it is fair to say that Meaningful Use is the most controversial health IT programme in the US, often criticised as an example of federal regulatory overreach, and for failing to ensure usability and interoperability. System suppliers and NPfIT leadership underestimated the power of the clinical community and the complexity of the NHS. The situation has improved with the development of a centralised procurement framework. O’Malley AS, Grossman JM, Cohen GR, et al. J Am Med Inform Assoc 2009; 16:153-7. These latter connections set the stage for higher levels of innovation and flexibility. It has resulted in near-complete implementation of EHRs in English GP practices. CCGs are led by GPs and now control most of the budget for buying hospital services for patients. While well intentioned (the leaders of NPfIT believed that this approach offered major economies of scale, created tremendous negotiating leverage, and ensured regional interoperability since everyone in a region would be on the same system), the flaws in this approach are now obvious. If there were a way to achieve these goals – to provide high quality, safe, accessible, patient-centred care at an affordable cost – without digitisation, that would be fine. The Code 4 Health Interoperability Community has taken this approach (supported by the new INTEROPen supplier community), and seems to be making good progress. Such systems should make it easy to upload to a suitable repository a screenshot of an unsafe interface, the user’s context (for example, doctor or nurse, clinical unit, and type of EHR system), and a brief description of the problem it created. Instead of creating a new agency to receive and analyse these reports, we favour adding them to the reports already collected by the National Reporting and Learning System (NRLS), now being managed by NHS Improvement (20). The odds of failure will be increased by focusing only on buying and installing IT systems without attending to issues like hardware, network stability and speed, workforce training and development, programme evaluation, and iterative improvements. It is about the A&E doctor having an accurate medication list when she evaluates a delirious patient, the oncologist having access to the results of a new clinical trial, and the ward nurse being alerted quickly that a patient’s changing vital signs may represent early sepsis. Table 3 shows the 3 stages of Meaningful Use (37). Throughout their development, these systems have been steered by strong user groups. This workflow needs to be anticipated and addressed. The lack of digitisation in the US outside acute care settings now presents a significant problem. Patient information, collected through GP EHRs, has been used in public-private collaborations for research, epidemiological surveillance and quality improvement. We endorse the recommendations of the National Data Guardian’s 2016 Review of Data Security, Consent, and Opt-Outs, which was commissioned to achieve this balance. “It's not something that I fear because I'm confident that's not going to happen,” Mazepin said. (It is worth noting that much of this help went to small office practices [the equivalent of GP surgeries], since HITECH aimed to digitise both offices and hospitals. This was sometimes funded by the practice itself (at times aided by the support of local hospitals) or through government research grants. We believe that another tranche of government funding (not yet allocated) will likely be needed to support a second stage (Phase 2, 2020-2023) of the strategy, as described under recommendation 6: While some trusts may need time to prepare to go digital, all trusts should be largely digitised by 2023. In 2014, the NIB issued its major report, Personalised Health and Care 2020, which laid out the broad strategy (50). The 2014 NIB report acknowledges that simply having a plan for implementation and interoperability is not enough to ensure a successful digital deployment.

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