Electronic Health Record - #EHR4NI - a vehicle for Standardisation?

Prof Rafael Bengoa

As you might have gathered from earlier entries in this blog, we in Northern Ireland are embarking upon a journey which will (hopefully) lead to a unified health data structure across the whole region. There are a number of reasons why we want to get all our health (and social care) data into a structure that is operative across many sectors, that reduces duplication in data entry, that is up-to-date and accurate, and streamlines the whole process of health care. It Makes Sense.


The DHSSPSNI have recently given approval to a Strategic Outline Case (SOC) which proposes developing a detailed business case for procurement of what we're calling the #EHR4NI - Electronic Health Record for Northern Ireland. This is potentially momentous - if all goes according to plan (!), Northern Ireland will have a unified health record for all its citizens, incorporating such items as outpatient records, prescribing information, lab tests, radiology and much more. There is also the prospect of bringing Primary Care (GPs) and Community Services into the mix, but the precise scope and detail have yet to be worked out.

In many ways this work directly assists delivery on the Principles of the Bengoa Review. (This is a major review of Health & Social Care in Northern Ireland, mandated by the Minister Mr Simon Hamilton, and which is taking place at the moment.) I'll be blogging at some point on how the Principles align with the #EHR4NI project, but one element that has been prominent in discussions has been that of standardisation of medical care across NI.

I have to declare that I am a fan of standardisation, so long as we're delivering meaningful outcome measures that we can reflect on in an effort drive improvement. If we are all doing things (largely) the same way, we can analyse the outcomes for our patients, and react quickly if things are not going as well as we would like. That's all well and dandy, but if we're all doing the same stuff, can that limit innovation and hence prevent us discovering other ways of doing things even better? Can standardisation be the enemy of best care? If we end up valuing the cookie cutter more than the cookie, we run the risk of missing important insights, demoralising our inventive and innovative health practitioners, and stalling the progress that our patients rightly expect.

Here's my worry - in the rush for an EHR4NI, we may end up simply doing things the way a Big Vendor decides we should do things. We standardise our processes to the standards of the incoming system. The constraints of the IT solution translate into constraints that we have to apply across patient care, because we have no other option. If we go back to the suppliers to suggest a Different Way of Doing Things, we risk being met with stony gazes and the reply that the process is set in stone (near enough). Or if we go to our Department of Health, they respond with a massive governance ask (submitting things to committees and review bodies etc) that stifles the little shoot of innovation before it even deploys its first leaves.

Standardisation, in other words, can become the engine of conservatism, and prevent the very improvements we're trying to achieve with the EHR.

Now all that sounds very pessimistic. But here's another scenario - we simply don't get the required agreement across multiple Health & Social Care sectors to allow us to move to a unified system, people start fighting with each other, and the whole plan falls apart. That is quite clearly worse than standardisation itself - BUT it's an outcome that many other EHR implementations have experienced grief over. It's a likely scenario, not an unlikely one. That's scary, and we need to avoid that at all costs.

Let's re-state what we want: we want the best evidence-based patient care, we want the right information at the point of care, we want near-real-time analytics to let us know how we're doing and to spot problems early, we want systems to help us do our job, and to help our patients better manage their own healthcare. We also want the data to allow the big decisions about resource allocation to be made in an informed manner.

So how can we make standardisation a force for good, not evil? How can we make sure that innovation is rewarded, creativity is encouraged, and changes are properly evaluated? I think the way around this is to explicitly state that standardisation has to be something that emerges from the bottom-up, rather than being enforced from the top-down. The role of the health managers, civil servants, committees and so-forth must be to curate and cultivate the front-line activity, to facilitate sharing of process data and outcomes, and to assist rapid regional adoption of improvements, using the EHR as a key enabler. If we make sharing an explicit part of the process, we create an evolutionary system where continual improvement can be encouraged - possibly even become inevitable.

This may mean we need to look at the EHR differently. The EHR can't be a single monolithic computer system - although that's how many people think of it, it's not possible to achieve the aims of #EHR4NI using this model. Instead, perhaps a specific core system could carry out a large number of the administrative and core clinical informatics tasks, but other platforms and sandboxes could tap into the underlying data structure to allow new applications to be developed, and new ideas trialled. This can be done without having to subject everything to a slow conservative process where deviation from the Agreed Norm, while not exactly heresy, becomes so mired in procedure, that we can't move forward.

Maybe even these thoughts are themselves heresy. Surely the People At The Top know best? I wouldn't count on it. The history of major ICT projects is littered with tales of projects going belly-up because they were treated as ends in themselves, rather than as vehicles to bring real benefit to patients and staff. Let's make this project one that we can be proud of.