Emerging Technologies and the Common User Interface CUI project in the NHS in England

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Emerging Technologies and the Common User
Interface (CUI) project in the NHS in England

• Dr Mike Bainbridge
• Clinical Architect
• NHS Connecting for Health
• October 2005

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Outline

• NHS Connecting for Health overview
• CUI
• Emerging Technologies
• Questions.

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NHS Connecting for Health

• Patient-based focus using high quality clinical
  systems
• Delivering
• Safety of care
• Added value for clinicians
• Value for money
• In England.
• Big Picture.
• Not a ward or an organisation but the whole
  service to the whole population of 50 million

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The Five NPfIT Clusters (NPfITs geographic
grouping of Strategic Health Authorities in
England)
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National Care Records Service (NCRS)
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The Spine clinical events through time
Patient info
Patient info
LSP
Patient visits AE
LSP
Patient visits GP
Patient info
LSP
Patient visits hospital
The information flow is repeated over time
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• ........so, as a patient, what do I want?

to be less at risk of harm than I used to be!
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I want people to care.. Or at least appear to..
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• .my record available wherever I am.

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Patient sees doctor in 3200 BC

• The iceman carried a series of tattoos to inform
  any doctor of his medical problems AND to
  identify relevant acupuncture treatment sites.

The HRCT scan of the iceman missed the arrow head
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Expectations of Healthcare have changed

• Paper is no longer fit for purpose

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It is unethical to carry on doing what we are
currently doing

• Professor Sir Muir Gray
• 01-Oct-2004

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Why do we keep records ?

• Patients records are not just for individual
  doctors, but are a way of communication with
  other doctors and healthcare professionals. If
  they cant be read then the doctors are failing
  in their duty to communicate effectively

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Medical Records Destroyed in Flood - shock
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Culture Change

• Security and Privacy are extremely important and
  must improve on current delivery

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New Challenges

• Clinical Genetics for example
• New needs for record keeping
• The shared record
• Confidentiality
• Implications
• Secondary uses
• Insurance / legal
• Records for all entities ?
• Born / Unborn
• Dead
• Medication and Pharmacy Specific issues

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Lets be grown-up about implementation as well
Whats wrong with this picture ?
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Outline

• NHS Connecting for Health overview
• Common User Interface
• Emerging Technologies
• Questions.

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Connecting for Health team

• Owner Mark Ferrar - Dir. of Infrastructure
• Clinical Dr. Mike Bainbridge Clinical
  Architect
• Dr. Peter Johnson Decision support lead
• Paul Frosdick Pharmacy and Medication lead
• Jo Goulding Terminology Lead
• Anne Cooper Nursing Lead
• Dr. Kate Verrier-Jones Research and Ethics
• Project Management Roarke Batten
• Analysis Miles Gray
• UX Design Kit Lewis

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The Common User Interface

• CUI Part 1
• NHS Desktop Infrastructure
• NHS Office
• CUI Part 2
• Design Guide
• Software Developers Kit (SDK or Toolkit)

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Microsoft NHS

• Enterprise Agreement (EA) signed during 2004
• EA has 3 terms of 36 month each
• Two (optional) renewals
• Covers Windows, Office other software
• Full Volume grows from 600,000 to 900,000
• Other software at lower volumes
• Joint commitment to CUI programme

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CUI Part 1

• NHS Desktop Infrastructure
• NHS Office

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NHS Desktop and Infrastructure

• What the workstream is trying to achieve
• Simplify building and deploying an XP desktop
  image
• XP environment configuration to support specific
  NHS requirements (e.g. Log On)
• A reduction in the complexity of a standard
  Windows Server 2003 based server platform
• Reducing the TCO of infrastructure via the use of
  Group Policy and directory design within an
  active directory

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NHS Desktop and Infrastructure

• What is in scope?
• Desktop customisation
• Desktop log on session management
• Desktop Automated build
• Application Compatibility
• Automated Build Application Integration
• Desktop Deployment
• Windows Server 2003 Base Platform Build
• Desktop Management
• Directory Services

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NHS Desktop and Infrastructure

• How are we going to do it?
• Requirements Gathering
• target existing NHS expertise
• form stakeholder group
• Use of reference implementations
• Production of Infrastructure Assets
• Ensure distribution and promotion of the
  Infrastructure Assets

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NHS Office

• Covers Office Professional
• Word, Excel, PowerPoint, Access, Outlook,
  InfoPath
• Ensures clinical utility
• How should Office apps support clinical tasks?
• Appropriate integration with clinical systems and
  data repositories
• Office user group set up for consultation

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NHS Office

• Configure common supporting features
• Research pane to search NHS information sources
• NLH
• Map of Medicine
• others
• Integrated medical dictionary
• Smart Tags linking to other applications data
• Templates consistent template usage and
  management

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NHS Office

• Two tier user group
• Reflecting size of current and future user base
• Scope to be determined by user group

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CUI Part 2

• Design Guide
• Software Developer Kit (SDK)

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National diversity

• NHS has procured a range of systems across
  England (for very good reasons)
• 3 major enterprise systems
• 4 alternative GP systems
• other specialist systems (eg. PACS)

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National diversity
(Cerner)
Boundary between enterprise systems runs through
densely populated areas
Multiple GP systems available in anygiven cluster
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Why CUI?

• Patient Safety
• Clinicians regularly cross borders will often
  need to learn new systems
• Risk introduced by different clinical
  applications performing same tasks in different
  ways
• Reduced (re-)training burden
• Clinicians switching between postings shouldnt
  need to significantly retrain to do same job
• Increase ROI (value)
• Raise adoption of NPfIT applications
• Get best value out of Microsoft EA investment,
  not just lower license costs

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Rationale Approach

• Design guide SDK will focus on patient safety
  and clinical utility
• Real world issues need to be considered
• Commonality is being addressed late in the day
• Systems are already in development
• Lots of work has already been done
• but theres a huge opportunity
• Financial sector spends 9x Health sector on IT
  per employee (Wanless report, 2001)

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What we mean by UI

• Overall user model
• Organisation, user input / output, screen layout
• Navigation
• Hierarchy eg. primary, secondary, local
• Components, nomenclature and copy
• Interaction design
• Principles behaviours
• Common display components
• Output and input of data / information
  knowledge
• Buttons, controls, tools and widgets, icons and
  graphics
• Accessibility features

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Clinical subject areas
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Approach

• Design to produce the best interface
• Not merely a good enough interface
• CUI deliverables must be better than anything
  currently out there or in development
• Iterative user-centred design process will ensure
  this happens
• Baseline current best of breed solutions
• Compare range of design solutions, conduct
  iterative development ensure user involvement
• Integrate technical, ISV LSP involvement
• Conduct comparative user testing, with existing
  proposed solutions
• Likely to result in broader adoption of standards
  already set by individual LSPs ISVs

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Approach
Iterative user-centred design process
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Information display

• How hard can it be? eg. Date format DD-Mmm-CCYY
• ISO standard is ambiguous on display, W3C
  standard does not specify separator and is
  ambiguous (ie. unsafe) in French
• Considering internationalisation (ie. French)
  makes English format awkward (eg. 04-Augu-2005)

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Icons symbology

• Review of symbols in use
• National international standards (lots of
  variation, inconsistency)
• Range of contexts (not just clinical)
• Framework for developing symbols / symbology
• What is a symbol?
• Why are they used?
• When should they be used? And when not?
• Risks of using symbols
• Clinical effectiveness of symbol usage
• More work required
• Review symbol usage in clinical applications
• Test principles recommendations with users

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Icons symbology - framework
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Abbreviations acronyms

• 2,860 abbreviations acronyms found in v.
  brief NHS survey
• CUI scope covers use in both display and input

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Terminology

• Aid interoperability between clinical records and
  systems by encoding patient data with a
  controlled clinical vocabulary
• SNOMED-CT is the NHS standard
• Standard NOmenclature for MEDicine Clinical
  Terms
• c. 350,000 concepts c. 1m descriptions
  synonyms c 1.5m relationships
• 18 base hierarchies
• Allows complex modelling of relationships between
  terms
• www.snomed.org
• Safe, optimal use of a national patient record
  system relies on clinical coding
• Adding codes to patient records is an effort (ie.
  unpopular) for users

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Terminology

• Initial scope Add codes to clinicians selected
  free text entries
• Must be SAFE, EASY and FAST
• Key requirements
• Users must be free to decide which concepts
  should be encoded
• The system must not try to automatically encode
  concepts
• Users must confirm the chosen codes
• The system must not rely on natural language
  processing
• The system must not make users encode everything
• Users must be able to encode rapidly and
  accurately
• The system must not interrupt users flow of
  thought as they make clinical notes
• The system must not constrain the accurate
  expression of an encounter between a clinician
  and a patient
• The system should offer near / fuzzy matches of
  terms when coding

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Terminology
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Medications management

• Focus on medication history the medication line
  item
• Single medication regimen is key building block
• Test use of DMD description
• Comparative design approach essential
• Multiple methods available for displaying dose
  syntax (DMD, Dundee, CEN)
• Many variations of possible data items for
  display
• Many existing patterns already in use
• Broad range of options from simple to complex

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Medications Management

• There is a lack of standardisation in the UK in
  describing medicines, appliances and medical
  devices, in how such descriptions are organised,
  and in linking knowledge required for decision
  support to these descriptions
• Information for Health
• Section 3.21

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Context
The need
7000 administration events per acute hospital per
day 1.6 million primary care prescription items
per day.
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The solution
A standard code and description for every
therapeutic product
Aspirin 75mg dispersible tablets
Aspirin dispersible 75mg tablets
Aspirin dispersible tablets 75mg
75mg aspirin tablets dispersible
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www.dmd.nhs.uk
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www.dmd.nhs.uk
The solution
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www.dmd.nhs.uk
The solution
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dmd and SNOMED CT
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Added value in systems
Requires changes to supply chain by the drug
manufacturers
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Accessibility

• Major NHS-wide issue must adhere to standards..
  but
• Proliferation of guidance means uncertainty
  among suppliers
• WINLOGO Microsoft Optimized for Accessibility
  Guidelines from "Designed for Microsoft Windows
  XP" Application Specification
• ISO 16071 ISO/TS 160712003(E) Ergonomics of
  human-system interaction Guidance on
  accessibility for human-computer interfaces
• 508 1194.21 Section 508 1194.21 Software
  Applications and Operating Systems
• IBM IBM software accessibility guidelines
• NDA Irish National Disability Authority
  Guidelines for Application Software Accessibility
  
• ATAG 1.0 W3C WAI Authoring Tool Accessibility
  Guidelines 1.0
• WCAG 1.0 W3C WAI Web Content Accessibility
  Guidelines 1.0
• UAAG 1.0 W3C User Agent Accessibility Guidelines
  1.0

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Accessibility
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Outline

• NHS Connecting for Health overview
• CUI
• Emerging Technologies
• Questions.

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• Proof or disproof of concepts

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The healthcare environment
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NHS Office
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Only successful if CfH products and services

• Diminish the current risk of patient safety
  incidents
• Mitigate against new patient safety hazards
• Concentrate as much on human factors as on
  technology itself
• Recognise the important role of the patient as an
  active participant

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Mobile Devices
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Ward Map
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Bedside Presentations

• By 2007
• All bedsides in the NHS will have a Pentium
  class machine running embedded Windows XP
• Current Uses
• Phone Calls
• TV
• Meal ordering
• Games
• Better Uses ?
• Clinical
• Focused Patient Information

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Concepts

• Ways of working
• Integration through a single record
• Ways of consulting
• Ways of educating
• Increased patient involvement
• Homework
• Forms for interviewing
• Knowledge delivery
• Healthspace
• Patient access to records
• Enforcing standards

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Joined-up thinking

• Technology
• Push the envelope
• Policy
• What are the implications before publication ?
• Safety
• MHRA / NPSA / HPA risk assessment built in
• Profession(s)
• What are the rules ?
• Do once and share.
• Patients
• Access / choice / involvement

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In 2010.

• No paper records
• Consent to share
• Genomic and other omic data
• Decision support
• Knowledge support

• All images
• Automated prompts and warnings
• Background data mining
• Feedback of research and evaluation into the
  service

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• Even at its scientific best,
• medicine is a social act.
• Davidov. 1998

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Questions ?