1. The evolution of Electronic Patient Records in the NHS, 1988-2003 Matthew Jones Judge Institute of Management University of Cambridge

2. An EPR by any other name … 1988 –Hospital Information Support Systems (HISS) 1994 –Electronic Patient Record 1999 –Electronic Health Record 2002 –Integrated Care Record 2/12/2003 –NHS care record

3. NHS IT strategy 1992 –Getting Better with Information 1996 –Implementing the infrastructure for IM&T in the NHS 1998 –Information for Health 2002 –Delivering 21 st Century IT support for the NHS

4. 1988 HISS programme £56 million on the Initiative £48 million in financial support to 16 projects at 25 hospitals £32 million on 3 main pilot projects, at Nottingham, Darlington and Greenwich. Significant delays in implementing key systems National Audit Office inquiry

5. 1992 Getting Better with Information Linked to White Paper The Health of the Nation Strategy guided by key principles: Information will be person-based Systems may be integrated Information will be derived from operational systems Information will be secure and confidential Information will be shared across the NHS Strategic initiative Developing an IM&T infrastructure

6. 1994-1997 EPR programme Demonstrator Projects, notably Queens Hospital, Burton and Wirral Hospital achieved successful hospital-wide implementation of EPR –Clinical focus –Strong management –Management/clinician partnership

7. 1998 Information for Health Lifelong electronic health records for every person in the country Round-the-clock on-line access to patient records and information about best clinical practice, for all NHS clinicians Genuinely seamless care for patients through GPs, hospitals and community services sharing information across the NHS information highway

8. Specific Targets Developing and implementing a first generation of person-based Electronic Health Records, providing the basis of lifelong core clinical information with electronic transfer of patient records between GPs Ensuring that all acute hospitals have the ability to undertake patient administration, including booking for planned admissions, with an integrated patient index linked to departmental systems, and capable of supporting clinical orders, results reporting, prescribing and multi-professional care pathways All acute hospitals to have level 3 EPR by 2005 (35% by 2003)

9. 2000-2003 Electronic Record Development and Implementation Programme (ERDIP) Demonstrator sites Key projects include –24 hr care, patient access, EHR –level 6 EPR –integrated primary & community care –direct booking, referrals, discharge, pathology messages –technical standards

10. 2002 Delivering 21 st Century IT support for the NHS Patient centred delivery of services Effective electronic communications, … cut the time to find essential information (notes, test results) and make specialised expertise more accessible for staff Improve management and delivery of services by providing good quality data to support NSFs, clinical audit, governance and management information

11. Integrated Care Record System Cross setting (including social care), multidisciplinary –no more silos National programme –Emphasis on infrastructure and ruthless standardisation 700-page comprehensive specification for ICRS Single system for whole SHA –Efforts focused on letting contracts for National Application Service Provider and Local Service Providers

12. Discussion 1 Onwards and upwards? –Progressively wider scope HISSEPREHRICRS Hospital admini- stration HospitalPrimary + Secondary + Community NHS (+ social care) Does this mean that EPR use has evolved in practice?

13. Difficult to see much evidence of progress for the NHS as a whole Big differences in EPR use between hospitals Not necessarily related to quality of management Investment decisions made by individual Trusts Some successful initiatives, but usually highly localised Rarely diffused more widely

14. Why? Priorities distorted by other initiatives (and IT low on the list) Performance measurement/ League tables Clinical governance/Clinical Audit Modernisation/E-government Lack of consistency Implementation approaches Strategy focus Competing healthcare IT functions Information Authority Information Policy Unit

15. HISSEPREHRICRS Implementation approach Pilot projectsDecentralisedPilot projects Centralised Strategy focusInfra- structure (data model) Developing working record Infra- structure (standard hardware) Lead organisation Information Management Group Information Policy Unit Information Authority National Programme for IT

16. Issues Build it and they will come Organisational change neglected Lack of communication Experience not shared NIH syndrome Unrealistic targets Aiming for the impossible, by tomorrow Little evidence of learning from failure to meet The best may be the enemy of the good Speed of response vs technology change vs policy change