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Title: Local Clinician Involvement in Clinical Information Systems: Necessity or Luxury


1
Local Clinician Involvement in Clinical
Information SystemsNecessity or Luxury A
Review of International Experiences
  • ASSIST (Harrogate, Preston)
  • October 1 2, 2003

2
(No Transcript)
3
Questions to be discussed
  • Is it important to solicit meaningful physician
    input early and often and act upon it?
  • Does finding meaningful ways to engage physicians
    require creating an organizational climate and
    culture that respects the heart of medicine?
  • Is this the key to maintaining physician loyalty
    and involvement?

4
  • Some management teams believe that ideas should
    be well fleshed out and ready for implementation
    before discussing them with physicians.
  • When that occurs, do physicians feel their input
    is actually sought?
  • And if they recommend changes at that point, will
    it be difficult for management to retreat and
    follow another course of action?

5
  • How can one best square the need for
    centralised/standardised policy with getting
    local support and use?
  • Does the opinion of national clinical bodies
    matter?

6
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT Clinicians Involved?

7
The challenge of being an afternoon speaker
8
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT Clinicians Involved?

9
EPR in Danish Hospitals
  • 11/14 counties have an IT strategy for the health
    care sector.
  • As of 2001, there were a total of 52 EPR projects
    in the country.
  • The projects were in different phases and were
    controlled on different levels
  • Between 5 and 10 of all beds in Danish
    hospitals are covered by an EPR system.

10
Whats most interesting about Denmark is
  • MedCom

11
Pre-MedCom
  • Late 80s
  • A GP who also worked P/T in hospital biochemistry
    lab
  • Chief pathologist at the hospital
  • Head of IT in the county
  • Proposed a project for Funen County IT strategy
  • Electronically transmitting lab results

12
MedCom Today
  • Over 90 of 2000 GP clinics/practices are
    computerized
  • 86 use their computers to send and receive
    clinical EDI messages
  • 10 of non-users
  • Those who will retire in next 3 years
  • Those just starting without the capital (1-2 year
    delay)

13
MedCom Facts
  • Used by ¾ of the healthcare sector
  • gt2,500 different organisations
  • All hospitals, all pharmacies, all laboratories
    and 1,800 general practices take part
  • Two million messages a month are exchanged (over
    60 of the total communication in the primary
    sector)

14
MedCom Facts (contd)
15
MedCom Facts (contd)
16
MedCom Facts (contd)
  • MedComs standardised messages implemented in 50
    IT systems, including
  • 16 doctor systems
  • 12 laboratory systems
  • 9 hospital systems
  • 4 pharmacy systems

17
MedCom Facts (contd)
  • Physicians pay for their own systems
  • Upcoming agreement with County Association and
    the PLO will mandate electronic communication
  • Specialists use of computers range from 40-90
    depending on the county with their use of EDI
    clinical messages ranging from 15-70

18
MedCom funders
  • 1/3 from Ministry of Health
  • 1/3 from County Association
  • 1/3 from Other Sources
  • Ministry of Social Services (recently)
  • Danish Doctors Association (early on only)
  • Dan NET
  • Danish Pharmacy Association

19
Seven Driving Forces
  • Communication benefits of MedCom
  • Improves dialog with hospitals
  • use to wait 5 days for results of tests (now
    almost as soon as it comes off the equipment)
  • Automatically notified when patient registered in
    an Emergency department
  • Discharge summaries now arrive within 1-3 days
    (use to be 4 weeks) standard set by Counties

20
Driving Forces (contd)
  • Out of Office Hours (OOH) system mandated
  • Started 1997
  • GP available from 1600 - 0800 hours (could be up
    to 3 GPs present)
  • 30 across the country some based at hospitals
  • Negotiated by PLO and County Association
  • GPs doctors had to learn how to use a computer if
    they wanted to be paid

21
Driving Factors (contd)
  • Peer influence collegial pressure
  • GPs go to see each others computers
  • PLO wrote conversion software to facilitate the
    transfer of patient data from one GP to another
  • Access to the Internet (2-3 times/day)
  • e.g. waiting times for x-rays for all clinics in
    Funen County
  • can see what procedures are done at each clinic
  • can decide with patient where they should go

22
Driving Factors (contd)
  • County Support
  • Provides GP with a diskette of all their patients
    when first starting (been doing since 1992)
  • Training done by data consultant visit practice
    regularly
  • Help desk
  • Practioner coordinator for each specialty
    (psychiatry, general surgery, etc.)
  • Works 2 hours/month
  • Coordinates wishes of GPs to hospitals and
    vice-versa
  • IT agenda moved forward through them

23
Driving Factors (contd)
  • 7. Standards set by MedCom
  • Contract signed with Counties and PLO obliging
    everyone to use them
  • Clinicians and vendors involved!
  • MedCom tests and certifies vendor systems
  • Steering committee of paying agencies meets every
    3 months to review compliance data

24
  • The Danish GPs are so automated that

25
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT Clinicians Involved?

26
(No Transcript)
27
New Zealand Facts
  • Over 95 of GP offices are using one of nine
    Practice Management Systems
  • 75 use their systems to electronically send and
    receive clinical messages such as laboratory
    results, radiology results, discharge letters,
    referrals, delivery of age-sex registers to their
    IPA/PHO, etc.
  • 50 of GPs now use the Internet on a regular
    basis from their offices - including
    communicating with their patients.

28
New Zealand Facts (contd)
  • Specialists use of computers range from 30-90
    depending on their region. The private
    specialist use of a full EMR is limited to
    15-20.
  • Like the Danes, GPs increasingly favor referring
    patients to specialists who are able to send
    information back to them electronically.

29
AGPAL ACCREDITED
30
New Zealand Facts (contd)
  • Used by 75 of all healthcare sector
    organizations in New Zealand.
  • All hospitals, radiology clinics, private
    laboratories
  • 1,800 general practices.
  • gt 600 specialists, physiotherapists, other allied
    health workers
  • Over 3 million messages a month are exchanged,
  • 95 of the communication in the primary health
    care sector.

31
PUBLIC KEY INFRASTRUCTURE
GP Practice
32
Driving Forces in New Zealand
  • Unlike the Danish success story, HealthLink
    received no government funding to initiate the
    service and its growth and success is based
    entirely on the market model of supply and
    demand.

33
Driving Forces (contd)
  • The development of IPAs (Independent
    Practitioner Associations) encouraged the uptake
    of information technology in primary care in New
    Zealand.
  • IPAs paid the costs for their member GPs to
    access the HealthLink network as part of their
    membership services.
  • HealthLink facilitated change by offering an
    electronic claiming only service for claims
    submission free of charge for the first 6 months.

34
Driving Forces (contd)
  • The past decade has also seen the emergence of
    the new position of Practice Manager within a
    physician general practice.
  • The Practice Manager has become a pivotal person
    to assist with the installation, management and
    training for any physician office system.
  • The Practice Manager responsibilities include
    financial management, IT and the human resource
    function in larger practices.

35
HealthLink increasingly used to assist with
chronic disease management
36
  • As a result of these applications of information
    technology in primary care
  • Child immunization rates went from 75 to 95.
  • Control of diabetes improved for patients with
    HbA1c higher than 9 pre-enrolment was 34 and
    this was reduced to 7 post-enrolment
  • There was an 80 reduction in wait time for
    statins for diabetes patients.
  • There was a reduction in acute admissions - this
    was running at 9 per annum. By 2002, the growth
    rate was reduced to near 0.

37
New Zealands critical success factors
  • A national health identifier NHI
  • Early adoption of HL7
  • Development and acceptance of the 1993 Privacy
    Act and the 1994 Health Information Privacy Code
    along with practical implementation of these
  • Mandatory electronic claiming for GMS (government
    subsidies for GP care)
  • Collaboration with private and public
    organizations
  • Multi-vendor co-operation and understanding of
    the business opportunities

38
NZ critical success factors (contd)
  • Healthlinks strategy has always been to work
    very closely with primary care physicians
  • to stay close to them and to support them.
  • HealthLink is intricately and comprehensively
    tied to the GPs
  • like the parmesan in the spaghetti is how one
    observer described it.

39
An interesting aside
  • At one stage the New Zealand Government spent
    several millions of dollars on an alternative
    product The Health Intranet of New Zealand.
  • This failed at the point where they tried to
    connect the Intranet to General Practice computer
    systems.
  • The GPs were very unhappy to let government
    representative agents touch their computers
    making the Health Intranet impossible to
    implement on the ground.
  • The government agents had no understanding of how
    General Practice works

40
NZ critical success factors (contd)
  • HealthLink employs nurses to act in liaison roles
    with General Practice, and so provide direct
    contact with the GPs.
  • HealthLink provides a help desk that has become
    the GPs first point of contact when requesting
    help with their EMRs - like the Danes.
  • HealthLink has also stayed very close to the GP
    system providers again like the Danes.

41
NZ critical success factors (contd)
  • HealthLink spend a lot of effort on demonstrator
    and beta testing sites.
  • They also work closely with the physician EMR
    vendors to debate projects thoroughly at all
    stages before during and after implementation.
  • Many of the HealthLink initiatives were a result
    of demand of the primary care physicians
  • e.g. discharge summary from hospitals, radiology
    test results (DI), orders (still in progress),
    delivery of claiming data i.e. responding to
    market needs

42
  • Was it important to solicit meaningful physician
    input early and often and act upon it?
  • Yes absolutely.
  • HealthLink has always worked very closely with
    physicians, physician organisations and physician
    EMR vendors to deliver quality information to
    General Practice. HealthLink always strives to
    be responsive to the physicians as its first and
    foremost obligation.

43
  • Did HealthLink find meaningful ways to engage
    physicians?  Did it require creating an
    organizational climate and culture that respected
    the heart of medicine?
  • Yes, basically by delivering a service that was
    totally devoted to serving the needs of the
    Physicians, by understanding the nature of
    General Practice as a business and acting always
    in accord with needs of General Practice.
  • The organisational climate and culture were /
    still are aligned to respecting physician needs.

44
  • Did HealthLink take the view that ideas should be
    well fleshed out and ready for implementation
    before discussing them with physicians?
  • Generally true although HealthLink also spent a
    lot of work on demonstrator and beta testing
    sites. They also worked closely with the
    physician EMR vendors to debate projects
    thoroughly at all stages before during and
    after implementation.
  • SG comment Many of the HealthLink initiatives
    also were as a result of demand of the primary
    care physicians (users of service) examples are
    discharge summary from hospitals, radiology test
    results (DI), orders (still in progress),
    delivery of claiming data i.e. responding to
    market needs

45
  • If so, did physicians feel their input is
    actually sought?   And if they recommended
    changes at that point, was it difficult for
    management to retreat and follow another course
    of action?
  • Yes. However, the focus of Health link has always
    been on supporting the physicians. Cant think of
    situations where Health link management had to
    retreat.
  • However, in discussing HealthLink, we should
    probably compare it with the New Zealand
    Government efforts to run its own network the
    Health Intranet of New Zealand.
  • In this case, management did have to make a
    serious and very public retreat.
  • There were several years of fighting while
    management tried to impose its will on the
    sector, but management ultimately lost.
  • HealthLink is now an authorised provider of
    network services for physicians, and has the
    blessing of the Health Intranet Governing Body.

46
  • How did HealthLink manage to balance the need for
    centralized / standardised policy with getting
    local support and use?
  • Health link undertook extensive consultation with
    the sector (mostly users rather than govt.) at
    all stages in the development, and ongoing work
    to get consensus agreement regarding policies and
    standards.
  • SG comment There were user groups, consultation
    with stakeholders before a new service (like Lab
    orders) could actually work i.e. preliminary
    steps with this one were agreement to work
    forward, LOINC code adoption, understanding of
    all issues from various stakeholders.
  • HealthLink also participated with teaching
    programmes involving all vendors and Practice
    Managers this was another way to obtain useful
    feedback from the market

47
  •  6.   Did the opinion of national clinical bodies
    matter?
  • Yes principally the IPAs who took an active
    interest in the debate.

48
The Kiwi docs are getting ready for
49
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT Clinicians Involved?

50
But first
  • Selected observations from the American literature

51
  • Much research has been done in an attempt to
    identify the key factors that predict EPR/EHR
    implementation success. Over 150 factors have
    been identified, but only two, top management
    support and user involvement are consistently
    associated with successful implementations.
  • Sittig D
  • The Importance of Leadership in the Clinical
    Information System Implementation Process
  • November 2001
  • http//www/informatics-review.com/thoughts/leaders
    hip

52
  • Experience suggests several factors that may
    increase acceptance and use of clinical
    information systems by physicians. First, broad
    physician involvement in the selection and
    implementation of the system from the outset is
    essential. Systems with no real sponsorship from
    the medical staff are likely to fail.
  • Anderson J
  • Increasing the Acceptance of Clinical Information
    Systems
  • MD Computing Jan-Feb 16(1) 62-5 1999

53
  • Clinician buy-in will require that their
    involvement is substantial and real. The project
    team must have strong clinician representation
    from the outset and throughout the project,
    including the planning, implementation, and
    post-implementation phases. Clinicians need to
    believe that the decisions they make matter.  
  • Krall M
  • Achieving Clinician Use and Acceptance of the
    Electronic Medical Record 1998
  • http//www.kaiserpermanente.org/medicine/permjourn
    al/winter98pj/emr.html

54
  • The need for physician involvement with clinical
    information systems has been advocated since the
    first installations in the 1960s. Even though
    the initial systems were rather rudimentary, the
    systems that were backed by strong physician
    leadership have been able to evolve and develop
    into sophisticated tools as information
    technology has become integrated into all facets
    of clinical care.
  • Schneider M et al
  • Physician Involvement in Clinical SystemsA
    Cost-Effective Investment
  • HIMSS Proceedings, Session 125
  • 2000

55
  • The healthcare systems that engage their
    clinical constituents early and often in the
    beginning will reap huge returns when these
    clinical leaders support the necessary changes
    that will occur as clinical information systems
    are rolled out.
  • Schneider M et al
  • Physician Involvement in Clinical SystemsA
    Cost-Effective Investment
  • HIMSS Proceedings, Session 125
  • 2000

56
  • Whether or not the CPR project leader is a
    physician, heavy involvement of physicians is
    common to all awardees, as members of both the
    CPR project staff and governing committees.
    Physicians with direct roles in the CPR efforts
    typically continue to devote at least some of
    their time to clinical practice, which appears to
    be important to retaining credibility with the
    medical staff.
  • Metzger JB et al
  • Lessons Learned from the Davies Program
  • 2000
  • http//www.cpri-host.org/davies/nuggets.html

57
One Particularly Relevant American Experience
  • Kaiser Permanente (KP) is a not-for-profit group
    model HMO (Health Maintenance Organization) with
    headquarters in Oakland, California.
  • The organization is divided into regional service
    areas spanning the United States from Hawaii to
    the East Coast.
  • It has used a centralized organizational model
    for their business and information technology
    operations since 1997.
  • Kaiser has eight million members and 80,000
    care-givers across all regions (2/3 in
    California).

58
  • The Kaiser Permanente Colorado Regions CIS
    implementation began with 2 medical office pilot
    sites (80 physicians and 80,000 members) in 1997
    and was successfully completed (500 additional
    physicians and 250,000 additional members)
    between March and October, 1998.
  • The region has achieved full CIS usage and has
    eliminated use of its paper records for all but
    archival purposes.

59
Kaisers research findings
  • 80 percent of the success of system
    implementations the size and complexity of KP-CIS
    is attributable to managing human factors.
  • Commitment from, and involvement of clinicians in
    the implementation of a project is of utmost
    importance.
  • Involvement is best achieved by soliciting active
    participation from both providers and staff from
    project initiation through project closure and
    beyond.
  • .

60
The KP approach
  • When Kaiser Permanente undertakes any project,
    the project leaders develop a series of Guiding
    Principles that provide direction during the
    entire project to the project team and to the
    larger KP community.
  • Once defined and accepted by executive
    management, these guiding principles are
    communicated throughout Kaiser Permanente.

61
The Kaiser CIS guiding principles
  • The leadership and sponsors must be visible,
    available, and supportive throughout the project.
  • The rationale for implementing KP-CIS must be
    understood across the Program.
  • Implementation activities must focus on realistic
    timeframes that address system usability at the
    point of care. CIS must be based on acceptable
    clinical content.
  • Providers and staff must believe that CIS
    enhances their ability to achieve superior
    clinical outcomes and improve provider/patient
    relationships.
  • Providers and staff must be continuously involved
    in CIS planning, implementation, and maintenance.
  • Regions must take the lead in implementing CIS

62
Kaiser guiding principles (contd)
  • Providers and staff must acquire the skills to
    effectively use CIS. Skills acquisition must
    accommodate individual learning styles.
  • Practicing providers and staff members must be
    engaged as members of the project team to ensure
    credibility with the staff, compatibility with
    the local culture and work flow, and clinical
    utility.
  • Honest, timely, regular, and pertinent
    communication to the user community is essential
    to adoption.
  • Providers and staff must be prepared to adapt to
    the changes that CIS will bring.
  • The appropriate technical and clinical support
    structures must be in place to ensure adoption
    and continued use of CIS.

63
Lessons to be learned from Kaiser
  • Unwavering executive support during the CIS
    implementation was a major factor in its adoption
    by the user community.
  • Implementing a CPR produces extraordinary change
    in nearly every facet of operations. Success
    would be unlikely without executive commitment to
    support of these changes.

64
Kaiser lessons (contd)
  • Early in the KP-CIS application development
    effort the designers found that there was no
    single best way to use a CPR in the clinic.
  • Hence, KP-CIS was designed to enable, not to
    enforce, changes in workflow processes, patient
    flow, and practice style.
  • Even the appearance of a workstation in the exam
    room causes clinicians to reconstruct their basic
    patient/clinician interaction.

65
Kaiser lessons (contd)
  • Identify and appoint physician-advocates
    throughout the organization.
  • Clinical workflow change is more successful when
    physician advocates communicate the rewards and
    benefits to the user community.
  • It is necessary to develop formal communications
    for physicians who are to use this new CPR to
    assist them in understanding how the system will
    impact their work.

66
Kaiser lessons (contd)
  • Provide regular feedback, progress reports and
    updates on project status.
  • This is essential to allay fears related to the
    high impact of a CPR on medical practice.
  • Ensure bi-directional communication throughout
    planning and implementation.
  • Offer frequent and consistent communications
    regarding changes under development.

67
Kaiser lessons (contd)
  • Identify and appoint representatives to the
    appropriate project teams.
  • Each department and facility will perceive they
    have unique needs. A variety of specialties,
    varying levels of practitioners, and geographic
    areas must be represented on project teams to
    account for these diverse perspectives.
  • The project teams serve as a forum to express,
    discuss, and evaluate differences in physical
    layout, physician practice style, staffing mix,
    and models from department to department and
    location to location.

68
Kaiser lessons (contd)
  • Plan for recurrent objection themes from
    clinicians.
  • A common provider objection is the perception
    that they must perform clerical tasks that take
    time away from patients.
  • Clinician order entry may seem to be more labor
    intensive for some primary care users than for
    specialists.
  • For example, internists may have more complex
    patients than pediatricians.

69
Kaiser lessons (contd)
  • Handling recurrent objections provides the
    ability to
  • Ensure usability and acceptance of change. If
    users do not perceive that the level of
    disruption will be minimized over time,
    acceptance of the change is compromised.
  • Address user expectations and concerns,
    especially during the first 4-6 months, when
    resistance to change may be most prevalent.

70
Kaiser lessons (contd)
  • One of the early steps in the implementation
    process was gathering requirements and making
    decisions about their relevance to KP-CIS in the
    first release of the product.
  • There was a balance to be achieved between
    functionality that was desired by clinicians
    versus functionality that was required for a
    successful implementation nationally.
  • Not everything could be included if business
    drivers, such as schedule and cost, were to be
    met. Yet legal, medical, or crucial operational
    functions had to be included in order to provide
    quality care to Kaiser patients.

71
Kaiser lessons (contd)
  • The KP-CIS project developed a deployment
    schedule that optimizes the use of national team
    resources but minimizes overall impact to the
    regional operations.
  • Each region is responsible for its own
    deployment, supported by the national KP-CIS
    team.
  • Each region is in a different state of readiness
    from an infrastructure point of view and each
    region has to work around its own operational
    constraints.
  • As an example, implementation during influenza
    season, a peak patient load time would be
    disadvantageous to patient care and to acceptance
    by clinicians.

72
Kaiser lessons (contd)
  • Because implementation and CIS acceptance is
    primarily the responsibility of each region,
    teams in the different regions were formed to
    manage the deployment and organizational change
    processes.
  • The team composition included practitioners,
    formal and informal leaders, clinicians with
    informatics expertise, representation from
    different specialties, and different levels of
    practitioners from varied geographic locations.
  • The likelihood of successful adoption increases
    as more types of potential users have a voice in
    guideline development and implementation plans.

73
In closing from Kaiser
  • Commitment from, and involvement of, end users
    (particularly the clinicians) in the
    implementation of a project was also of utmost
    importance. Involvement is best achieved by
    soliciting active participation from both
    providers and staff from project initiation
    through project closure and beyond
  • Wolfe J
  • Implementing a CPR to Serve Kaiser Permanentes
    Eight Million Members
  • HIMSS Proceedings, session 85
  • 2000

74
Everything in life is relative
75
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT Clinicians Involved?

76
  • Crucially, all of the ERDIP projects have
    involved clinicians and had clinicians on the
    local project teams. "We would not have achieved
    all we have without the level of clinician
    involvement we've had."
  • Philip Crouch
  • ERDIP programme manager
  • http//www.nhsia.nhs.uk/text/pages/inform/informis
    h6/informp5.asp
  • 2003

77
  • The Walsall ERDIP project was managed by a small
    team with the support of the NSF groups. This
    close involvement of clinicians was important and
    any national programme office will require people
    with operational experience. It is also
    necessary to avoid turning larger programmes into
    a project management industry.
  • Walsall Core National Evaluation report
  • 5/11/2002

78
Key messages for ICRS, derived from the South
Staffordshire experience
  • The EHR is still in its early stages of evolution
    so that continued learning from formative and
    summative evaluation, co-ordinated across
    different communities and different suppliers,
    will be important.
  • Questions of who will be responsible for this and
    how it is linked to system supplier performance
    will need to be answered.
  • South Staffordshire Electronic Record
  • Development and Implementation Project
  • Final Evaluation Report
  • July 2003

79
Key messages for ICRS, derived from the South
Staffordshire experience
  • ICRS will facilitate new ways of working through
    process redesign and culture change, and should
    be designed as part of a whole systems approach.
  • There is a need for clearly defined sponsorship
    and management arrangements adopted as part of
    the national implementation, which might include
    Primary Care Trusts, clinical networks and Chief
    Information Officers.
  • A successor to the LIS process is required,
    taking account of new NPfIT developments, to
    support integrated systems development across
    local communities.

80
  • There needs to be an effective national lead with
    clear links to national priorities and
    implementation arrangements.
  • National roles include policy leadership,
    decisive action on outstanding implementation
    issues, implementation support and a co-ordinated
    change management, evaluation and learning
    programme.
  • There are major issues to be resolved around the
    NHS/Supplier boundary, including the involvement
    of suppliers in community wide system strategy
    development, agreement on data sharing policy,
    allocation of responsibility for process resign
    and benefits realisation, project management
    roles, and integration of systems across
    boundaries.

81
  • Dr John Pilling stresses not only the careful
    preparation necessary for such a scheme, but also
    the absolute need for clinician involvement
    throughout and constant liaison, through a
    committed project team, between all those
    involved. These are lessons that are of equal
    validity not just for this PACS project, but for
    every IT project in the healthcare field.
  • http//www.bjhc.co.uk/issues/v19-7/v19-7editorial.
    html

82
And from New Zealand
  • UK - Clinician involvement essential in IT
    planning says BMJ
  • http//www.hinz.org.nz/ihealth/ihealth.htm

83
  • It is not the choice of device but involvement of
    clinicians that counts.
  • I could go on, but there is no, one solution that
    will fit all clinical scenarios. It is
    imperative that clinicians are involved in all
    these discussions and that we do not decide what
    types of mobile devices will work for them.
  • Sue Wilson
  • Head of IMT (acute services)
  • Sherwood Forest Hospitals NHS Trust
  • http//www.e-health-media.com/news/item.cfm?ID496
  • Aug 18, 2003

84
Fear not, we are making progress
85
EHR and ICRS similarities
  • They are both complex change management projects.
  • The challenges surrounding change management are
    more significant than the technical issues
    involved.
  • They both necessitate a migration from a
    patchwork legacy situation to the future long
    term vision.
  • Success will not be achieved without a planned
    and phased migration.
  • They both demand clarity about the vision for
    local health care services and the way that IT
    and information will be used to underpin them.
  • They cannot be implemented by either the private
    or the public sector working alone.
  • A clear and well managed division of
    responsibilities will be required.

86
Outline
  • The Danish Experience
  • The New Zealand Experience
  • An American Experience
  • The British Experience
  • NPfIT Clinicians Involved?

87
NPfITs official position
  • Patient, clinician and supplier engagement is
    critical to the ultimate success of our solution.
    We
  • are meeting regularly with SHA chief executives
    and four lead CEOs
  • are integrating the work of the 28 CIOs with
    NPfIT
  • have a consensus from the Medical Royal Colleges
    on a core patient summary or data spine
  • have consulted with over 240 clinicians and NHS
    IT professionals in producing the initial OBS
  • have now got a core group of clinical
    representatives working in the Design Authority
  • We recognise that two way communication and
    involvement is vital.

88
  • Professor Martin Severs from the University of
    Portsmouth has joined the National Programme as
    Director of Clinical Assurance he will take the
    lead on developing and ensuring clinician
    involvement in the National Programme.
  • Professor Severs told the conference that in his
    first three weeks in post he had already reviewed
    levels of clinician involvement
  • I found there extensive levels of involvement of
    clinicians at all levels of the programme. He
    admitted that this finding had quite surprised
    him.
  • E-Health Insider
  • National Programme 'Mobilises' for Delivery
  • 27 Mar 2003

89
  • The National Programme stresses that clinicians
    and other NHS staff have been consulted on
    specifications and requirements from the outset.
    Most of the input into the OBS for ICRS has come
    from clinicians working full time in the NHS,
    stated Mr. Granger.
  • Professor Peter Hutton, head of clinical
    engagement with the national programme, added In
    two to three weeks there will be an announcement
    on a route in for almost everyone in the NHS to
    be involved. From that point on we will be taking
    a lot more note of individual user requirements.
  • Granger Confirms Centre to Allocate LSP Contracts
  • E-Health Insider
  • August 14, 2003

90
But there are other views
  • A particular concern is limited engagement with
    clinicians so far.
  • Lack of clinician involvement has been a
    consistent theme in past failures.
  • There is a culture here that means you just
    cant force solutions on clinicians, they have to
    be cajoled and persuaded.
  • E-Health Insider
  • April 2003

91
  • Despite some early discussions, many general
    practitioners and consultants have not heard of
    the integrated care record service or the
    information spine.
  • Nick Booth
  • Sharing patient information electronically
    throughout the NHS
  • BMJ, 327114-115, 19 July 2003

92
  • News of the National Audit Offices involvement
    in reviewing the national programme was first
    reported in Computer Weekly this week, in a
    report which stated that the NAO would examine
    arrangements for managing high-level risks on the
    NPfIT and arrangements for gaining the local
    commitment of clinicians.
  • E-Health Insider
  • August 22, 2003

93
  • Over many years, NHS informatics developments
    have suffered from being under-utilised by their
    potential users. The position of informatics
    should be stressed to empower decision makers to
    take steps to harness its capability, notably
    through ensuring that clinical involvement in
    informatics is enhanced and integral to day to
    day working, without which few health informatics
    systems will perform up to their promise.
  • BCS Health Informatics Committee ASSIST
  • More Radical Steps (2003) Initiatives
  • August 2003

94
Questions to be discussed
  • Is it important to solicit meaningful physician
    input early and often and act upon it?
  • Does finding meaningful ways to engage physicians
    require creating an organizational climate and
    culture that respects the heart of medicine?
  • Is this the key to maintaining physician loyalty
    and involvement?

95
  • Some management teams believe that ideas should
    be well fleshed out and ready for implementation
    before discussing them with physicians.
  • When that occurs, do physicians feel their input
    is actually sought?
  • And if they recommend changes at that point, will
    it be difficult for management to retreat and
    follow another course of action?

96
  • How can one best square the need for
    centralised/standardised policy with getting
    local support and use?
  • Does the opinion of national clinical bodies
    matter?

97
Let the discussions begin
98
ICRS roll out
  • Phase 1 by end 2004
  • Phase 2 by end 2006
  • Phase 3 by end 2008

99
ICRS phase 1 - 2004
  • Booking of outpatient appointments online
  • NHS email and access to online knowledge
  • Electronic laboratory and radiology results
  • Some clinical communications e.g. GP referral
    letters
  • Providing simple functionality and making best
    use of existing systems

100
ICRS phase 2 - 2006
  • Access to a more detailed patient record
    including
  • specialist results
  • GP prescribing record
  • hospital discharge summaries
  • Digital imaging
  • Computerised referrals and requests
  • Migrating on to active and interactive
    functionality

101
ICRS phase 3 - 2008
  • Working towards full integration of health and
    social services including
  • decision support software
  • screening
  • community wide prescribing
  • computer support for care planning
  • Supporting advanced features e.g. telemedicine
  • Continuing development and enhancements

102
Key milestones
  • Summer 2003
  • Final Output Based Specification to be completed
    for ICRS
  • Short-list of LSP applicants to be finalised
  • October 2003
  • Initial contracts to be awarded for two LSPs
    (London and North East England)
  • Contract to be awarded for e-booking service
    provider
  • November 2003
  • Early implementation work commences
  • December 2003
  • Further three contracts to be awarded for
    remaining LSPs
  • April 2004
  • National roll out of Phase 1 of ICRS begins in
    earnest
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