PAC gives NPfIT six months to deliver CRS

Tags: applications BT CSC Electronic patient records England Health HIS Hospital hospitals Lorenzo Millennium NPfIT patient Primary Care system systems

27 Jan 2009

The National Programme for IT in the NHS should be given six months to get effective care record systems into acute trusts, the House of Commons Public Accounts Committee has concluded.

After that, it says the Department of Health should “assess the financial case for allowing trusts to put forward applications for central funding for alternative systems compatible with the objectives of the programme.”

Despite its desire to see strategic care record systems deployed speedily, the latest report from the PAC says the DH should assess the capacity of the national programme’s two, remaining local service providers – BT and CSC – to see whether they are capable of meeting “their substantial commitments.”

In particular, it says this should be done before trusts in the South take systems supplied by the LSPs. However, it notes there are “considerable problems with existing deployments of [Cerner] Millennium” and “serious concerns about the prospects for future deployments of [iSoft] Lorenzo” – the two strategic systems on offer.

Indeed, the PAC says plans for the deployment of Lorenzo across the North, Midlands and East of England “should only follow successful deployment and testing in the three early adopter trusts.”

Lorenzo is currently in limited use at South Birmingham Primary Care Trust and University Hospitals of Morecambe Bay NHS Foundation Trust, with a further deployment due in Bradford.

Despite the moderate tone of the PAC’s report, chair Edward Leigh said: “The risks to the successful delivery of the National Programme for IT in the NHS are as serious as ever.

"Essential systems are late or, when deployed, do not meet the expectations of clinical staff. Estimates of costs are still very unreliable and, despite action to secure their commitment, many NHS staff remain unenthusiastic.

"Trusts should not be expected to deploy care records systems that are not working properly. If there is no improvement in this situation within six months, then the DH should consider allowing trusts to apply for funding for alternative systems.”

The PAC issued a critical report on the national programme in 2006, and then ordered the National Audit Office to conduct a further review, on which it held hearings last year. Richard Bacon, a member of the committee and long-standing critic of the programme, went further than Leigh in his response to the latest investigation.

“In its current form, the programme is in deep trouble from which it is unlikely to recover,” he said. “The programme’s central aim was to create detailed electronic patient records but this is now so far behind schedule that hospitals are walking away. Hospital trusts should now be free to buy the systems they want, subject to common standards, and they should be funded to do this through the national programme.”

Bacon also issued a statement directing journalists to E-Health Insider’s exclusive story about Worthing and Southlands NHS Trust potentially ditching its Millennium system as an example of the kind of problem that the national programme was facing.

The PAC report also examined the first benefits statement for the programme and said that future statements should be audited by the Comptroller and Auditor General.

It was also highly critical of the confidentiality agreements that the DH has entered into with CSC regarding reviews of the delivery arrangements for Lorenzo. It said these were “unacceptable” because they “obstruct Parliamentary scrutiny of the DH’s expenditure.”

The DH claimed it was pleased with the report. “New IT systems in the NHS are delivering better, safer and faster care,” it said in a statement.

“Current costs have declined because of the delays to implementation, due mainly to adding extra functions to the system. Costs are also controlled by the contracts which only pay to providers once the service has been successfully delivered."

Link:

House of Commons Public Accounts Committee: The National Programme for IT in the NHS; progress since 2006. The report is on the PAC website.

Lyn Whitfield

Reader's Comments

Mission Impossible

28 Jan 09 05:01

The timescale is unreal. The Granger programme is not going to deliver in 6 months. We all know that. And - no doubt - so do the PAC.

Common sense

gillsr@iee.org

28 Jan 09 08:01

Finally some common sense!

Hopefully trusts will be able to get on with buying systems that are tailored and work rather than ones wrapped up in so much red tape they become a shadow of what they could be. Let's hope all the smaller innovative EPR providers haven't gone to the wall...

Lack of acute progress is not the worst of it

28 Jan 09 09:01

Progress with the delivery of acute hospital systems is lamentable and it is almost certain that the delivery of level 3 EPR systems (for those who don’t remember the 1998 NHS IT Strategy – Information for Health; these are systems that integrate PAS and departmental systems with order comms, ePrescribing and clinical noting) has been significant less than that which would have occurred if the NPfIT had never existed.

However, even if the NPfiT had universally delivered acute hospital systems it would still have failed in its core objectives, which I thought were about the sharing of information across care settings with seamless support for patient’s journeys along integrated care pathways. If the PAC think that the lack of progress with acute systems is the worst of the problem they are letting CfH off lightly.

The NPfIT has delivered some useful national infrastructure and services that probably would not have existed without it but most of the progress claimed by LSP in areas like PACS and community systems would have almost certainly happened at lower cost without them and their impact on progress in primary care and the acute sector has clearly been negative.

The core of the problem is the belief by Politicians that the challenge of implementing IT successfully in the NHS is a generic one and their continuing faith that appointing able people, with no experience or understanding of Health and Health Informatics to key leadership roles in both the major contractors and NHS will solve the problem.

Progress requires that we build on the little that has been successful delivered and preserve the skills and understanding that have been slowly and painfully developed in CfH and its contractors. The barriers to sanity erected in the original LSP contracts need to be demolished, but just because the baby has shat in the bathwater we should still try and hang on to it now it is showing signs of learning to walk.

Lorenzo

28 Jan 09 10:01

Having seen several demonstrations of Lorenzo, I seriously doubt whether it can ever work in UK hospitals, let alone within 6 months. IMHO the terminology is appalling and so staff will not only be expected to learn a new way of working but also a new dictionary.

This was reported to CSC and iSoft months ago but nothing has been changed. As an example: 'Find Appointment' will now be 'Search for a Scheduling Opportunity'! A Consultant will be called a 'Service Provider'. Who in CfH agreed to this?

Personally, I would not want to be working in one of the Early Adopter sites.

Re: Lorenzo

28 Jan 09 11:01

Does anybody know if the terminology is Read Codes or SNOMED?

With the benefit of hindsight.

28 Jan 09 11:01

Remember back at the beginning, we had Egton Medical frozen out of the process, now (i undertand) we mau have EPIC Systems standing back allegedly saying the contract terms are just not workable. May we may have a situation where EPIC and EMIS, two of the providers who could have had a decent chance of pulling this of, may have a way in. Yeah its hindsight, but it’s an interesting "if only".

I have to imagine some folks at E.M.I.S feeling vindicated right now.

(post edited by EHI)

A long time in politics - not software

28 Jan 09 11:01

We should know if any Secondary Care Trusts had a realistic chance of full operational go-live within the next 18 months let alone six!

(Not included in 'go-live' here are 'pilots', parallel running with old systems, 'acceptance testing' and other mysteriously unspecified deployments. Let's also stipulate in this definition that a system sending a message to the great bit bucket in the sky is not enough - the message content has to be used in receiving systems - striking out many of the supposed CfH 'wins'.)

From where I sit this report looks like vacillation by (yet another) bunch of well meaning folk who don't understand the health service or it's software afraid to make a strong decision.

Who could forget the NHS Care record Service: Indicative Deployment Plan - Jan 2005 v 2.0?

http://www.e-health-insider.com/img/document_library0282/deploy_plan_0105.pdf

I am sure CfH would rather we did... it was fiction.

That CfH don't have a clue what the 'position' will look like in six months is reason enough to call time now.

re: Lorenzo

sleepyfox@gmail.com

28 Jan 09 13:01

In answer to the above question about Lorenzo: "Does anybody know if the terminology is Read Codes or SNOMED?" - the poster when saying "terminology is appalling" was referring to the language used within the application e.g. "'Find Appointment' will now be 'Search for a Scheduling Opportunity'".

This has nothing to do with Clinical Terminologies, as both Read Codes (v2 and v3) and SNOMED support both standard and localised synonyms for terms. Instead it is purely down to the configuration of the Lorenzo application, which would have been decided by the Trust, iSoft, CSC and primarily CfH. I would imagine the shift to terms like 'Service Provider' is simply CfH following DoH's new guidelines on use of language, but not currently working on the Programme any more I'm sufficiently far away from the coal face to say with authority.

What I can say is that the configuration of the data types and the screens for an EPR/EHR system (which we referred to at the time as 'tailoring') in an Acute setting typically takes a team of 50+ people over 12 months. There are over 1000 screens to set up for instance. Just getting the various customer representatives at a site to agree on what data items would be labelled on the screen, and which one goes at the top is an effort in an of itself, and this is for a simple Trust - Supplier relationship, not the much more complex Trust - CfH - Prime Contractor - Supplier relationship that exists in the National Programme.

re: re: Lorenzo

28 Jan 09 16:01

50+ people for 12 months!

Wouldn't it have been better to employ some clinicians to design these and test them with their colleagues.

Better still, pay the BMA/RCS IT people to do this exercise for you - then you get their buy-in.

No wonder things are a mess...

Fixing the wrong bit

28 Jan 09 20:01

The PAC response matches the whole problem surrounding NPfIT: looking at the wrong objectives. They fret about delivering tin (hardware, etc.) rather than 'are we really making healthcare delivery better?'. Perhaps if we focused on the real objectives we might get the systems we need when we want them. It was Tony Blair's wish to have a quick fix in time for the election which got us into this mess, where deadlines are set for installations when it was always a 20-year business transformation process (especially given the state of the NHS). 'Information for Health' started this off on the wrong foot with its silly timetable for delivery. The other half of the problem is that the professions are not taking the lead about what is needed for 21st-Century medicine. They are quite right to complain that they are not involved, but they should have been demanding the right solution in the first place. To be fair, some individuals have been pushing for this, but most of the professions seem to resist change rather than planning for it.

50 person years? who knows

29 Jan 09 01:01

re: 50+ people for 12 months Yes, good design takes time, experience, leadership, application, and patience. It takes much much much more than this too.

Calling a slot a "Scheduling Opportunity" is the sort of corporate **** that should alert you to ditch your LSP, or challenge your staff.

If the poster who thinks a gaggle of clinicians can turn out good desing by wafting thier expertise, as a chef wafts truffle, then they are missing the point, but in a Rumsfeldian way, not spotting their own knowledge gap.

Health informatics as a discipline (not a calling) separate from nursing or medicine, separate from bean counting or generic IT, or digital infrastructure, or from security, it intersects all these. It intersects natural language processing, information science, compuational linguistics, and PAS, yes PAS!

The RCP guidelines are useful, they were awaited for some years, and are the pinnnacle of consensus between cliinicians. We do look forward to these being extended, but please have some limited regard for the thousands of mere mortals trying to make this **** deliver some benefit to citizens and NHS staff.

Some key parts of a national infrastucture have been creeping forward and are now taken for granted, thats how change happens, you only notice it when its taken away; PDS, ETP, and smart cards, soon SCR.

The PAC is right to press for more, realistic objectives, if their view is unrealistic, look how far out some medics are!

Clinician buy in

29 Jan 09 09:01

I went to the first unveiling of the IDX product for the south back in 2004.

After a lot of effort by clinician focus groups, CFH and other interested parties a final(ish) product was to be shown to interested parties from trusts.

I seem to remember it ended up in a rather acrimonious discussion between the presenter , trust staff and CfH as to what went where and how it would work, or not, in their particular trust.

So even if we get a system designed by Clinical bodies it doesn't mean it will be accepted by a trust.

Take a Long View

tim.benson@abies.co.uk

29 Jan 09 09:01

Sometimes it pays to take the long view. Back in 1971, the El Camino hospital in California implemented the world's first hospital-wide EPR. It met "massive resistance from important segments of the medical staff, spreading quickly to ... national newspaper headlines. This resistance, initially justified in part by early system shortcomings, seemed intractable."

Sounds familiar... The resistance was overcome "by effective leadership of the more visionary El Camino physicians." The outcome was: "Ten years later ... the hospital inpatient cost per case is 40% less than the county average for 13 similar community hospitals."

"It is often said that those who do not learn from history will be forced to relive it"

"Never forget that introduction of a [EPR] into a hospital impacts a *human* organization to perhaps an unparalleled degree. If the need to manage the change process is ignored, resistance and even rebellion may be reasonably predicted... Success has repeatedly been demonstrated to be the consequence of each doctor, one at a time, coming to see how his performance is enhanced by investing his always scarce time in learning how to use [it] efficiently. Similarly hospital managers must participate in and buy into a carefully designed benefits realization program before they can be reasonably expected to act."

[source of all quotes: Hodge MH. History of the TDS Medical Information System. In Blum BI and Duncan K (eds). A History of Medical Informatics. ACM Press 1990, 328-344.]

50+ people for 12 months!

29 Jan 09 11:01

I'd like to second comment number 11, and remind some others that the days of designing "systems" on the back of an envelope are long over.

Re: 50+ people ....

29 Jan 09 13:01

The days of designing systems on the back of envelopes may be over .... but I bet there are still a lot of systems designed that way that still in use years later!

Didn't someone once say: "A legacy system is one that works"?

50+???

29 Jan 09 13:01

I have no idea if the quote of 50+ and 12 months is correct. If it is, then in my mind as software engineer, there is something fundamentally broken in either the requirements or the implementation if it needs this level of resource per trust.

Its is this level of local configuration and customising of systems that has always been a huge part of the problem with implementation in the NHS. It is utter madness

Just what exactly is it that makes one Acute Trust so different from another?

50 person years

sleepyfox@gmail.com

29 Jan 09 14:01

It seems some people have taken my '50+ people 12+ months to tailor a EPR implementation' a little out of context.

The implementation costs I was referring to were the observed real-world resource levels for a comparatively simple installation in a reasonably sized US acute-care facility. More importantly this was for the simple 'customer buys from supplier and gets what they want' model that exists most everywhere in the world other than the National Programme. Furthermore the 50 people in question were all supplier-side, I did not have access to the resource opportunity cost of the many clinicians/admin staff/consultants from the customer who contributed to the configuration of the system.

In the 3.5 years I worked on the London LSP project BT Health had more than 600 staff in London, and IDX/GE more than 300 in their London office. I am not sure how many staff CfH had in London during that period, but from the size of the one office I was familiar with at St. Pancras I am guessing 150-200 in that building alone. During that time two major installations of an EPR system went live: University College London and Queen Mary Sidcup.

It is obvious that the National Programme was a demonstrable example of 'inefficiencies of scale'.

The winds of change

sleepyfox@gmail.com

29 Jan 09 14:01

Tim Benson makes (as usual) an excellent point - one that many of us consultants have banged on about since the beginning of the National Programme (and before) - that NPfIT was/is fundamentally a *change management* programme, and not an IT programme.

Curiously enough neither BT nor (to my knowledge) Accenture, CSC or Fujitsu brought in (or had in-house) change management specialists with domain knowledge of healthcare. This was a serious shortcoming, the results of which we have seen. Doctors are people, just like the rest of us, and react similarly when someone moves their cheese.

To poster #16 who wrote: "there is something fundamentally broken in either the requirements or the implementation if it needs this level of resource per trust" - all I can say is: "Yes, these systems really are that complex". If you haven't worked on an EPR I can see how you might underestimate its complexity. For example: LastWord had >10,000 screens and >10,000,000 lines of code. The RFI for the National Programme had over 4,000 individual requirements, some of which even though running to more than a single page of A4 were woefully inadequate to actually describe the information actually needed to implement a feature, and spawned their own "Further information for clarification" documents, some of which ran to >100pages.

I've worked in finance, and even global risk forecasting systems are less complex. Healthcare is a big and complex domain, and the acute care setting is the monster of the family.

When you are in a hole.....

29 Jan 09 15:01

....stop digging !

If 6 months is going to make the difference, we must be mighty close to having solutions from both Cerner and Lorenzo which fully meet the Functional Spec and are fully compatible with NHS requirements.

We see billions being pumped into failing financial institutions, and billions being pumped into a failing IT program.

When is our government going to stop digging ??

Why not use something that works

29 Jan 09 15:01

Why not use a EPR, PACS, PAS etc solution that works?

Ok it's outside the national program but does what it says on the box.

Siemens Soarain EPR works with OMSL PAS and Siemens PACS along with pathology and other clinical systems.

It works now, in the real world.

Legacy Systems and Moden Best Practice

29 Jan 09 21:01

Comment # 15 "...Didn't someone once say: "A legacy system is one that works"?..."

I'll lay good money on it that the technical documentation required to support the application does not exist?

In defence of clinicians

sue.wilson@swbh.nhs.uk

30 Jan 09 02:01

I sometimes get quite annoyed at the attacks on clinicians. Anyone who thinks a consultant, GP etc, can not articulate, what he/she needs from IT to make their clinical practice more efficient, I personally think is naïve.

They may not know all the solutions, but can ask the right questions. Of course if you take time to ask them in the first place.

They want something slick, simple and no barmey language, that makes their job easier.

Tim Benson is correct you have to get your champions to start with, as they help so much in engaging the masses.

In my Trust, we have our champions who are very active. They have worked with us to design a "passive EPR" which links in with our Active EPR (iCM). Let me tell you they are actively involved in all implementations and cascade key messages out to their colleagues to bring them on board.

Many of these consultants drive forward quite difficult projects, participating in design and implementation, acknowledgement of results, paperLITE projects, handover reports, supporting Hospital at Night, Infection control.

We now have ECG traces coming on-line, Endoscopy reports, and other images, and the driver was their needs, not ours in IM&T.

Well I could go on.

What makes an acute Trust different, someone asked? Besides having some software, it is all about having a culture of change, that involves clinical staff, and more importantly communicating and listening to them.

Implementing Electronic Patient Records is not easy, it is hard work,and we are not perfect by any means,but without the clinicians on board, it is sheer impossible.

Barmey language in Lorenzo - get rid of it, as it will never be accepted by clinical staff. I can hear the sarcastic quips now!! Keep it simple, please!

Winds of Change some times

ted.yeoman@nhs.net

30 Jan 09 09:01

I worked for a now defunct PCT as a Changed Specialist during an Accenture lead NPfIT implementation (interesting word). The LSP did have "Change Managers" but it was only after we had broken 2 that we got one that was prepared to understand the processes beyond what the book said. We did get a better system for Child Health and a Community System that looked like it would work until it got merged in the larger PCT. I then moved to a Hospital Trust doing a Fujitsu Cerner deployment (another interesting word) as an internal change person. Fujitsu had Change Managers too their main role was to make sure the business processes were changed to match the needs of the system. To effect long term change the "service" needs to want to change, that is the real role of the Change Manager to help the service identify the ways it can work better and finding, developing and facilitating the take up of new useful tools while finding strategies to minimise the downsides of the new tools.

Until the concept that that change is a bottom up process is truly taken on board by CfH and their suppliers, the Programme will continue to be blocked by people who feel disempowered and deployed too and told to implement.

Why were the words interesting ... they are both "doing too" words not facilitated change words like a "TPP enablement" or "accessing Cerner"

Integration

georgebrown@bulldoghome.com

30 Jan 09 10:01

I'm not familiar with the applications in comment 20, but most 'legacy' applications do not integrate with others.

For example most Pharmacy dispensing systems do not integrate with Laboratory, and Prescribing systems - and this is within the acute environment only. There no effective solutions out there that offer information transfer of data relating to patient care from the acute systems to the primary care systems (e.g. from the hospital to the GP).

Back to the future

30 Jan 09 11:01

I didn't know whether to laugh or cry at R Bacon's recommendation that "Hospital trusts should now be free to buy the systems they want, subject to common standards, and they should be funded to do this through the national programme.”

The NHSIA/Information for Health approach was based on the first part of this (standards) but crucially without the second (national funding). The philosophy here was one of engagement and persuasion but here were no levers (and I mean things as basic as a "business case" which clearly spells out why and how the necessary investment of human and financial resources would deliver improvements in health outcomes) to persuade Trust Boards to invest in information systems rather than beds, wards, drugs,.... I think we gave this approach about three years.

When senior DH folk lost patience with the lack of traction, they threw the baby out with the bathwater by setting up the centrally funded and tightly centrally controlled NPfIT. I'm too polite to describe the new philosophy which accompanied this but let's say it was not strong on engagement and persuasion. As a change management approach, it failed. As a contract/commercial management approach, it failed. And I think we've given it six years, so somewhere along the line DH learned the art of patience.

If Richard Bacon is right, and that's still a big "if", then in shaping the post-NPfIT approach, we need to ensure that lessons of what did and did not work are learned not just from the National Programme but also from Information for Health and the NHSIA.

Third time lucky, anyone?

Commercial confidentiality?

30 Jan 09 12:01

(e-mail concealed because of unacceptable levels of spam, when revealed last time)

Can we be sure what the purpsose of commercial confidentiality is, in regard of NPfIT? Perhaps this quote from the PAC report gives us a clue as to why NPfIT has failed:

"Confidentiality agreements that the Department made with CSC in respect of two reviews of the delivery arrangements for Lorenzo are unacceptable because they obstruct parliamentary scrutiny of the Department’s expenditure."

Perhaps too much is hidden behind closed doors, that if revealed would demonstrate to all, that NPfIT is not yet a viable programme.

Re: Integration

30 Jan 09 15:01

"I'm not familiar with the applications in comment 20, but most 'legacy' applications do not integrate with others." (post 24)

HL7 anyone? There are plenty of 'legacy systems' out there that integrate effectively using this industry standard.

HL7 and Integration

georgebrown@bulldoghome.com

30 Jan 09 16:01

Last time I looked at HL7 (was some time ago - so I might get corrected here) - there were no HL7 messages supporting medicines management, pharmacy nor prescribing.

Anatomy of a disaster, in slow motion - one clinician's perspective

01 Feb 09 11:02

As a clinician with almost 20 yrs of experience in medical IT and varying degrees of engagement with the various layers of bureaucracy dealing with IT in the NHS, I have long ago come to the conclusion that the proposed solutions won't work, were designed & are being implemented by people without much of a clue & instead of improving the delivery of healthcare, actually make our working lives more difficult. My position now is to ignore the rubbish being punted & proclaim a pox on all their houses.

Some of the commentators here seem to think that clinicians know very little about designing IT systems that work. The simplistic answer is that the ones who are any good are not the ones listened to as they are likely to burst bubbles & management doesn't like killjoys. Not just in IT, just consider the general state of NHS management.

I think a short summary of the last 10 years will best illustrate this:

1988 - 1997 - Interest in IT, admin & financials experience for healthcare facility, develop clinical application for department.

1998 - Early - Propose to develop an integrated EPR solution in conjunction with an acute trust that was ahead of the UK curve & using clinical ordering / discharge summaries & pharmacy by means of an extended Mckesson system. Told to wait for national policy.

1998 - Late - National policy with no clear direction - Change of guard at the trust, management get seduced by technobabble & start dreaming of cutting services at one site & providing them by means of teleconferencing. Self - fund development of demonstrator for tele-radiology application for use in A&E and seek permission to trial - not forthcoming.

1999 - Work with clinician tasked by DH with advising on EPR. Clinician more interested in reviewing literature, writing a paper.

2000 - Extend demonstration project to other departments & rich clinical content. Continue to self-fund as no NHS backing available (NHS Institute says only fund research, trust not interested, banks haven't a clue & Dot Bomb means First Tuesday etc not an option)

2001 - Small scale demo in one department with possibility of being taken up by local cancer network which then fizzles out. Discussions with IT department ongoing but suggestion that now waiting on new national policy & hence not investing in IT.

2002 - Tout project around, everyone looking to DH.

2003 - NPfIT on drawing board, consult for NHSIA as part of 50 strong clinical advisory team drawing up requirements. Team scrapped after one meeting, one mini assignment to review incomprehensible & illogical document written up by business analyst. Control passes back to 6 man team at DH.

2003 - 2004 - Bidding process & after, discussions with bidders to be part of core clinical team. Laugh on hearing the core of proposed solutions but no room for own proposals as partners already tied up. BT & Fujitsu don't want to know as they feel have consultancies already lined up. CSC don't want to listen. Accenture offer a role & then withdraw claiming budgetary constraints, how when only 5 clinicians for whole region? - CfH pipedream of seconding NHS consultants on the cheap to blame. IBM offer role but do not win.

2005 - 2006 - Watch the antics, attend a few meetings where ask a few awkward questions of Richard Granger & Harry Clayton, hear from lots of people about how there are very few clinicians knowledgeable about IT. Work in hospitals that have deployed systems & wonder at procurement processes.

2007 onwards - Ignore, occasionally look up CfH requirements for clinical advisers but no appetite for working under fools implementing broken systems with no scope to improve. Watch proceedings in despair & wonder if saying "I told you so" is a cheap shot.

2009 - Decide my time too valuable to waste & trust can employ people to fill IT blanks on my behalf as am too busy treating patients.

http://www.frontpointsystems.co.uk

To the moderators, please feel free to split into sections or post separately if long.

NHS IT - and the NHS in general

01 Feb 09 19:02

"As a clinician with almost 20 yrs of experience in medical IT and varying degrees of engagement with the various layers of bureaucracy dealing with IT in the NHS, I have long ago come to the conclusion that the proposed solutions won't work.."

I could not agree more - I've been involved for over 23years and no longer work for neither the NHS nor the LSPs - I got fed up with being surrounded by fools incapable to make **any** decision (right or wrong).

I will say this however - IT is a full time job - the NHS has got to grow up and fund it properly. You cannot do it as a part time job after attending ones ward rounds.

On fools and decision-making ...

02 Feb 09 12:02

Fools or otherwise, during my time in NHS IT the groups from whom I always found it most difficult to get a consensus decision on what was wanted were the various clinical factions within the NHS!

Point 20 clarified

02 Feb 09 13:02

Siemens Soarian EPR, Oasis PAS, CRIS, Siemens PACS, JAC and Clinisys Pathology are not legacy systems, they do exactly what they say on the tin, and they work. These systems integrate with each other. HL7 messaging compliant, what more do you need? These systems are much further forward than Lorenzo and Millennium may ever be.

HL7 messaging compliant

georgebrown@bulldoghome.com

02 Feb 09 16:02

........Pharmacy dispensing, Prescribing, and medicines administration - I'm interested to know what the relevent HL7 v3 messages are relating to the above processes?

Can anyone point me in the direction for the relvent messaging technical documentation supporting these processes please?

HL7

03 Feb 09 09:02

There seem to be two arguments here. One is that dispensing and prescribing messages do not exist within HL7. The other is that 'legacy' systems do not integrate with others. These are separate issues. The first will affect both 'legacy' and LSP systems equally. The second is just not true. Just look at the number of Choose and Book appointments processed by Trusts using legacy PAS systems.

And the Spine??

03 Feb 09 09:02

re point 32-- and do these systems satisfy the requirements of NPfIT and are they spine compliant?

medicines etc

03 Feb 09 10:02

The latest HL7 3 MIM with the information you require is available for download from hl7.org.uk by registered members.

Might have made sense for CFH to make it a bit more widely available.

Standards

03 Feb 09 11:02

".....download from hl7.org.uk by registered members....."

And this typifies the approach taken by the LSPs and CfH - and is precisely why the program has failed.

How can anything be a "standard" and yet be kept from joe public - only accessible by "registered members" - who no doubt will have to part with cash to see it - whether medicines management is supported or not - and I guess not?

NPfIT MIM on TRUD

03 Feb 09 11:02

The NPfIT Hl7 V3 message implementation manual(s) are now hosted on the excellent NHS Terminology Reference Data Update Distribution Service. Registration is vetted but free.

https://www.uktcregistration.nss.cfh.nhs.uk/trud/

MIM content on TRUD is a recent addition. The move followed brief uncertainty over the HL7 UK website when its (then) hosts CSW folded. It is also still available via HL7 UK site.

Meanwhile [apropos of nothing] "Through the Looking Glass" was not an implementation manual for Wonderland. Lewis Carroll did not release it in Major Versions 1 through 7 with around 40 minor releases over a five year period. Neither does it unzip to over 250 megabytes of documents.

HL7

03 Feb 09 11:02

HL7 does indeed have very detailed and well used standard messages for all the domains mentioned in this thread and has done for several years. Many also have CFH specific variants in the MIM. See www.hl7.org.uk and www.hl7.org. There is no mystery about it. Rik Smithies, Chair HL7 UK

Through the Looking Glass

tim.benson@abies.co.uk

03 Feb 09 12:02

One of the problems with many standards is that not everyone understands what the writer meant in exactly the same way. It is too easy to jump to the wrong conclusion. Alice was always willing to ask: ‘I don’t know what you mean by “glory”’ Alice said.

Humpty Dumpty smiled contemptuously. ‘Of course you don’t – till I tell you. I meant “there’s a nice knock-down argument for you!”’

‘But “glory” doesn’t mean ”a nice knock-down argument”’ Alice objected.

‘When I use a word,’ Humpty Dumpty said in a rather scornful tone, ‘it means just what I chose it to mean – neither more nor less.’

‘The question is,’ said Alice, ‘whether you can make words mean so many different things.’

‘The question is.’ said Humpty Dumpty, ‘which is to be master – that’s all.’

- Carrol L. Through the Looking Glass and What Alice Found There, 1871 p 102

Re point 32 + 35

03 Feb 09 18:02

Clinisys Path will have to be SPINE / NPfIT compliant - BT are starting to install it in London trusts! As to whether or not this systems will be used instead of Millenium's path functionality or just an interim solution - that I'm unsure on.

Glass Ceilings

04 Feb 09 15:02

Worth you all looking up MIT90s work which shows that interfaced systems only bring a level of benefit, at which point you hit a ceiling and need an integrated product to bring greater process change across the chain of organisations. This is what NPfIT is trying to build, an integrated product across organisations. The reason it has taken so long is because it doesn't/didn't exist as the NHS never invested in it.

Why do SAP and Orcale have one product covering all the areas of a business? Because that's how you get the process improvements and the ultimate return on the investment.

The process improvements that are required across the pathway can only be brought about from integration, not interfacing. The NHS now needs to survive and needs this process improvement. Remember change is not an option for the NHS as more people will retire than leave school soon, so it has to work differently and more efficiently. It cannot do this on pen and paper alone nor on interfaced systems - which also cost more to run over the life of the systems.

Interfaced systems won't support the level of change required... end of ... business realised this 15 years or more ago...

Glass ceilings and stones

05 Feb 09 20:02

Interfaced systems that work to improve efficiency and workflow would be (and in my area are) a whole lot better than integrated systems that don't.

And scratching below the surface of the supposedly integrated Cerner solution, it was apparent that there were quite different products in the suite, with superficial integration, and different navigational properties and data structures. And IDX appeared far worse.

Doing things in a consistent way does not mean having to pretend that buying from one supplier solves all your problems or de facto achieves integration.

I'd prefer to get our clinicians using good interfaced systems now, and clamouring for better integration in 10 years, rather than trying to force them to take half-baked and overpriced solutions. Incremental progress, including taking the users with us, is a high priority for me.