The HI revolution

It may be helpful to try and define “health informatics” and the people who supply health informatics services and support before building the case for their importance in patient care, says Mik Horswell

Making Information Count (Department of Health, January 2002), the NHS human resources strategy for health informatics professionals, used the following definition which has been generally agreed to sum up the scope of health informatics: "The knowledge, skills and tools which enable information to be collected, managed, used and shared to support the delivery of healthcare and to promote health."

Drafting a functional map for the profession, the Health and Social Care Information Centre describes the key purpose of health informatics as: “To enable, promote and support the effective use of data, information, knowledge and technology to support and improve health and health care delivery.” This appears to set a firm consensus!

To translate this into recognised activities and groupings within healthcare, it is usual to include the more technical end of information & communications technology staff, information/data analysts, knowledge managers, health records staff, senior managers and directors of services, clinical informaticians and those involved in education, training and development in IT etc.

The development of these groups into a recognisable profession – health informatics – has largely mirrored the introduction and development of computing in the NHS and private/independent sector providers over the last 30 years. There is, therefore, a dependency between technology and systems and those that develop implement and maintain them.

This is not to say that there is no longer a requirement around paper based records systems as still found in most secondary care/hospital services for keeping patient medical records, but the future clearly lies with electronic patient records. Witness the transformation in primary care since the early pioneer days in the late 70s when simple electronic records complemented the paper-based Lloyd George envelopes with their myriad of little cards and attached letters and reports.

Now it is virtually impossible to find a practice that does not routinely use only electronic records rather than paper in consultations with patients and also for prescribing, audit, recall systems, monitoring, appointment booking and other aspects of clinical practice.

In the United States a similar revolution has been taking place, stimulated partially by the complex insurance based funding of healthcare and the need for detail costing of care and treatment. In January 2009, Barack Obama was quoted as declaring his plans for healthcare records:-

“To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that within five years, all of America’s medical records are computerized. This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests. But it just won’t save billions of dollars and thousands of jobs – it will save lives by reducing the deadly but preventative medical errors that pervade our health care system.”

In fact, there is a worldwide consensus that electronic systems are the future for healthcare and a look into Australia, western and increasingly eastern Europe and in Asia will demonstrate a whole raft of initiatives that are being adopted and followed elsewhere.

Some of the current system developments that support direct patient care that we see in today’s NHS are outlined in the box.

It does not take much imagination to work out that to suggest removing all of these systems would meet with virtually universal opposition. Health informatics and electronic systems for handling information are essential parts of the modern healthcare systems and it would be unthinkable to try work without them.

If you view the healthcare service from a consumer perspective, you can also see how important health informatics has become. We live in a world where it is commonplace to use the internet to order everything from groceries to airline flights, we monitor bank accounts, talk online to friends across the globe and if you are under about 25 years of age, your main social networks are probably electronic! Why then, should we expect anything less from our healthcare services? The generation that is increasingly leading those services has been born into the computerised age and was schooled to use the technology, where appropriate, to support their day to day activities.

Patient safety is enhanced by the use of identification techniques such as barcoded wristbands, linking patient to pathology test and to pharmaceuticals dispensing. Radio frequency identification (RFID) is used on tags for babies and children to monitor their personal safety and movements. Clinicians are quickly contactable through mobile telephony and email. Electronic records are always available at the interface between clinician and patient to support accurate diagnosis and appropriate treatment.

Just to use a recent simple personal experience as a consumer with a chest problem, my GP appointment was booked by telephone at my convenience. I logged on via a touch-screen receptionist on arrival and the consultation recorded on my electronic record. Follow-on treatment included calls via mobile phone from the GP after test results were received, a visit to my preferred pharmacy where my prescription was awaiting collection, a telephone conversation with the hospital outpatient booking centre to get an appointment to fit my diary. Inconvenience to me – virtually none. Outcome and satisfaction so far – very high.

It would be wrong not to mention the concerns that will always exist around security and confidentiality of personal information in healthcare. This is a very real priority for all involved in health informatics as well as for clinicians.

This is not a new issue. Hippocrates covered this in his oath around 2,500 years ago and healthcare professionals use virtually the same rule now. If something is shared in confidence, it should only be further shared with the consent of the subject. We have used that approach with our confidential paper records and are now adding additional security with electronic records through secure sign-on and use of smart cards to identify individuals with legitimate relationships with the patient and therefore allowed to access records.

It is also essential to acknowledge the role played at board level in the acquisition, development and use of health informatics in any healthcare organisation. This must not be seen merely as a job for the techies! It requires board level leadership like all other aspects of modern healthcare, purely because it is now an integral part of what everyone does. For example what would we do without email?

To return to the need for a lead in the development of professionalism amongst staff members, this will come from many directions but consider the importance of a few:-

• Defining what the roles entail through Knowledge & Skills Framework, Skills for the Information age etc., driven by central government initiative.
• Local leadership and prioritisation through the NHS organisation at board level.
• Personal support and development from professional organisations such as the British Computer Society, ASSIST (Association for Informatics Professionals in Health and Social Care), Institute of Health Records and Information Management (IHRIM) etc.
• Development of professional status though accreditation and registration with UKCHIP (the UK Council for Health Informatics Professions)

We have already travelled so far with the introduction of health informatics into the way we now work in healthcare provision that we no longer think of it as a separate issue. It is part of the way we do business and part of the patient pathway through healthcare. Its continued development and investment in it are things we ignore at our own risk.

PULLOUT

“there is a worldwide consensus that electronic systems are the future for healthcare ”

Mik Horswell is c ommunications & media director, UK Council for Health Informatics Professions

www.ukchip.org

BOX OUT

• Picture Archiving and Communication System – the replacement of old film x-ray systems with digital imaging, enabling controlled storage and sharing of images, avoiding repetition and allowing remote access and consultation. This has expanded to include technologies such as ultrasound, magnetic resonance, PET, computed tomography, endoscopy, mammography, etc. Leading edge in 2004, all hospitals now use these technologies.
• Prescribing, stock control – General practice and some hospital systems offer electronic production and transfer of prescriptions directly to pharmacy and then dispensing and consequent stock control and ordering/purchasing.
• Pathology systems – the actual processing and examination of most specimens is now computerised and the subsequent production, storage and transfer of results and reports is also mostly electronic. In many areas the transfer of results from laboratory directly into general practice electronic records is the norm.
• Electronic appointment booking – some GP practices allow patients to book appointments via their websites and the national Choose and Book system for direct outpatient appointment booking during or shortly after GP consultation has now reached usage of about 50% of total outpatient referrals. This gives patient choice of date and time for their appointment and helps reduce cancellations and DNAs
• Waiting list management – managing and reducing waits for both outpatient appointment and elective inpatient admission has been a target for electronic systems since the first patient administration systems emerged in the 1970s. With current political imperatives demanding a maximum 18 weeks between referral and treatment, advancing sophistication has become essential to monitor all aspects of the patient journey through the healthcare system.
• Theatre management and scheduling – a key step in the process of patient care is ensuring maximisation of theatre resources – space, surgeon, anaesthetist, nursing and other specialised staff and electronic systems are almost obligatory.
• Specialist clinical services systems – developed to meet specific demands from clinicians ahead of the development of comprehensive electronic health care records. Cardiology and dermatology are popular solutions.
• Maternity – again developing since the 1970s, systems that support the flow from ante-natal through delivery to post-natal care and then special care baby unit care when required.
• Bed management – another part of the picture of hospital resource usage facilitating maximisation of available resources.
• Care records – electronic medical records - developed over a period of 30 years in primary care to the current position, but remain the holy grail of the secondary care sector, being the key plank of the National Programme for IT that remains incomplete despite huge investment of funds. There have been very well publicised reports of the size of investments, complexity of contracts, difficulties in developing the software (Cerner’s Millennium and iSoft’s Lorenzo) and departures from the programme of leading suppliers (Accenture and Fujitsu). However there remains consensus that electronic patient healthcare records are here to stay.