13 March 2016

A single health record for Northern Ireland? #EHR4NI

The Health Minister has unveiled the eHealth Strategy for Northern Ireland, and a key part of improving services for patients, and ensuring we can deliver high quality health care in an environment of continual improvement and patient engagement is an electronic health care record (EHCR) which brings together data from a multitude of sources and makes it available to inform what we do as health care professionals in many different environments. The plan also calls for patients to be able to interact with their own information - to view their doctors' letters, communicate with health professionals, arrange appointments, see their medications and access health promotional materials.
Dark Hedges, Co Antrim. Photo: Bob McCallion (Farm Life)
Unsurprisingly, this is a complex and potentially costly undertaking, and we're talking about doing it at a rather large scale. Not that our population of 1.8 million is particularly large, but the potential numbers of sectors involved means that there is a great deal of work to be done if we're working towards a single record.

One fairly significant problem is that a product that integrates all aspects of a patient/client's data (I'm going to try to avoid using the word "care" for reasons I've partly already outlined) doesn't actually exist - yet. The big integrated health platforms that are widely used in the US and elsewhere are marvels of software engineering, and do allow us to potentially do some very valuable things, but they are at best only part of the solution, not the full package. And I think this is an important point - when we are lookng at our strategy and where we are going, we are not looking at the product, but at what we are going to do. An EHCR project is not a procurement exercise for an IT solution, it is a redesign of how we (patients, doctors, nurses, allied health professionals, government etc) develop and support ways of working that make the most of what we have available.

A significant part of the challenge is linking together data from sources such as paper hospital records, GP systems, community systems, pharmacy, government etc, and making it actually work for us. This is not a trivial proposal, and there is no doubt that it's not all doable at once. The "change management" (or "service improvement" or whatever we end up calling it) presents enormous difficulties, and if you're mapping this across a health economy of tens of thousands of front-line staff and something like 500 different system installations, the potential for problems is very high. In many (perhaps most) cases where an "all-at-once" change was tried (the "Big Bang" approach), the experience was not at all straightforward.

It's clear that a skilled team is required to lead the change, and that team may need to be large. Where do we find these people? If we take them out of their front-line jobs (which we will have to - we need skilled and innovative doctors, nurses,AHPs who know their subject areas and their patients), how do we back-fill their positions with similarly skilled people to keep the services running? In Northern Ireland, being across the water from the rest of the UK, this may not be achievable.

To cut this long story short, I don't think we can do a "Big Bang" in Northern Ireland at the present time, even if a product was available off the shelf. One proposal which has been put forward is a bimodal approach - implement a version of a large EHCR for central hospital functions (including a patient portal), while in parallel working on an integration of specialist systems onto an open-standards data platform, such as one based on OpenEHR specifications (for example).

This has a number of potential advantages. We can stage the implementation over a longer period, allowing the system to adjust. We can continually review progress and change direction if required. We can foster innovation by providing an open standards platform that is accessible to smaller vendors and to health-delivery organisations themselves. We can avoid "lock-in" to a single vendor. We can support a more open and dynamic IT landscape. We can develop a cadre of healthcare professionals who are highly engaged with improvement. We can get patients and clients properly involved at a real decision-making level.

Some disadvantages may also be perceived - the whole process may take longer to bring benefit than a Big Bang. Standardisation may suffer if there is too much "innovation". Silos of data may re-emerge if not constrained in a single system.

My view is that the disadvantages of a bimodal approach are perhaps overstated, and in any case are not avoided by a monolithic Big Bang. We're on a journey here, and we have to accept that there will be a great deal of diversity in health systems even in the best case scenario of a Big Bang. We'll know we are on the road to success when we are moving towards a world where the data is secure and consistent, as well as independent of the system that is used to generate or display it. And far more importantly, where health decisions, whether made by patient or healthcare practitioner, are based on the very best and most up-to-date data.

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