Yesterday at HC2012, I found University Hospital Birmingham’s (UHB) Prescribing Information and Communication System (PICS) and I was not disappointed. Ok, perhaps I was slightly disappointed but more on that later.

I explained that I have heard good things about Electonic Prescribing in PICS from other doctors. A nice man who introduced himself as the head of software development promptly corrected me that PICS is much more than an electronic prescribing system but a whole Electronic Patient Record with ordering, results, medicines administration, discharge letters, clinic letters, referral management, handover, patient list management and electronic patient observation system underpinned by a robust rules-based engine.

I was hooked for the next 60 minutes!

This is a system that can:

• Automatically can prompt a nurse to consider not administering a medication if there is a recent blood result that suggest that this action might lead harm. This can happen AFTER the drug has been prescribed and without a doctor ever having seen the blood test.
• Suggest blood tests for the following day if blood results from the previous day was unexpectedly abnormal but won’t suggest it if this was a longstanding abnormality.
• Send automatic alerts to the urgent response team if a patient’s heart rate, blood pressure or temperature hit certain alert thresholds. If there is no acknowledgement or response it even knows to keep chasing the team!

The is integration at a level that I have only ever seen when I visited the US last year and observed the VA’s VisTA system in action. PICs however, takes the integration between clinical systems and information to a different level.

At UHB, the medical director supports IT development directly and distributes decisions about IT to the respective clinical directors. Here is medical leader who understands that you cannot remove IT decisions from the same people making clinical decisions at this hospital. Brilliant!

Then my inevitable question come up: Is PICS OpenSource? After all, it is developed by NHS staff funded by tax-payers.

Sadly not.

After spending quite a lot of money on development of PICs, UHB is keen on recouping its investment. They teamed up with a commercial company and gave it sole marketing and distribution rights.

Changing topic quickly, I asked a about new enhancements and upgrades. The man explained that they have a lot of amazing ideas but can only develop so much, as their manpower and skill set is limited. I then told the story on how OpenEyes, a fully OpenSource EPR harnesses the coordinated development effort of 3 teams in 3 different countries, collaborating for the benefit of all.

The nice man’s eyes then flicked across to a representative from the company commercialising PICS and said to me, ‘perhaps you should speak to him.’ So I did and was greeted with silence and a wry smile.

I thanked the nice man for entertaining me for the last 60 mins and left the booth thinking to myself, ‘the NHS has amazing people creating great IT, if only they are allowed to collaborate and work together. If only…..’

Recently, I had the privilege of visiting a VA facility with 200 inpatient beds, an emergency department, a large outpatients department and several long term care facilities (ie. nursing homes). Every site uses VistA. I spoke to 4 attending physicians (consultant equivalents) and the chief medical officer (Medical Director). They were incredibly gracious with their time and were not short of opinions!

‘VistA makes it easier for us to do the best we can at chronic disease management and preventative care. For example, when a patient is diagnosed with diabetes, automatic alerts are generated to remind us to perform routine disease monitoring such as eye checks and neurovascular assessment of the feet. All of this information is captured in a structured way so that we can continuously monitor our performance. Sure, it more time, but we are confident that our patients get the care they deserve. This is less common in the private sector, as longer consultations and preventative medicine does not generate any monetary compensation.’

Throughout my visit, different clinicians were very keen on demonstrating to me the ability of VistA to access records on any patients wherever the patient was based. This was what made it possible for the VA to ensure continuity of care for their patients during the city wide evacuation when Hurricane Katrina devastated New Orleans in 2005. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1854987/]. Back when Tony Blair was making the case for Connecting for Health, he said that if he ended up in Accident and Emergency in Bradford, he wants the doctors there to have access to his GP records in Guildford.

‘You are impressed with BCMA, surely not!’ This was the response from one of the more senior physicians when I mentioned that I was very impressed by their bar coded medicines administration (BCMA) system that ensured that the right patient, get the right medications at the right time. He continued, ‘We had this for years. This is nothing to be impressed about. After all, supermarkets have been doing for this decades.’ Slightly taken a back, I was embarrassed to admit that in NHS organisations, even those with electronic prescribing and medicines administration systems, do not come close to this level of sophistication.

More than an hour into our discussions, I was starting to feel guilty that I was eating into their clinical time given that I arrived unannounced! A bit like racing car drivers critiquing the performance of their cars, the doctors here have clearly formed a working relationship with VistA and was keen to share their views with me. Like any symbiotic relationship, they were equally critical in what they perceive as the slow progress for improvements in the system (details in a separate post). ‘At the VA we have become experts in utilising electronic patient records to improve the quality of care out patients receive’. I aspire to the day that I’m able to say the same of myself and my colleagues here in the UK.

Just before I left, I met with the chief medical officer. Clearly proud of the VistA system, he explained how it allows him to ensure that his organisation maintains and drives up the quality of patient care.’ I know how well each of my doctors are doing. For example, in diabetes, I can find out the average HbA1Cs for different groups of patients. If one of my doctors are under performing, I can show him/her the evidence and agree a plan of action.’ He continued, ‘Do you know why the private sector did not just pick up on VistA? It is free after all.’ I shrugged. ‘Traditionally, the design of their IT systems were driven by billing and reimbursement requirements, VistA is not particularly good at that.’

As I was leaving the facility, my guide pointed out to me how the hospital has changed over the last 10 years; less inpatient beds, larger outpatients department and expanded community services. It then occurred to me, VistA has not only shaped the way their doctors work, it has shaped the whole organisation and enabled care delivery systems that could not have existed otherwise.

I wondered to myself, what if Connecting for Health delivered the vision it set out way back in 2002. How would the NHS look like today? It is sobering to note that the VA already had this level of IT functionality at the turn of the millennium.

How much longer can the NHS afford to wait?

About the author
Dr Wai Keong Wong is a Haematologist in Training in London. Wai Keong is fellow on the NHS Medical Director Leadership and Management Scheme. He hopes to acquire skills that would allow him to drive up quality by aligning systems and processes which will remove barriers to safe, effective and personal healthcare – something he believes all patients deserve. He believes passionately that a fully integrated clinicians driven electronic patient record based on open standards is central to achieving this vision. He recently had the opportunity to visit a VA hospital whilst he was in the United States.

This is a story of two hypothetical John Smiths; one who lives in the US, and another in the UK. They both fall ill on Christmas Eve 2011.

Scenario 1: New York, USA | Veterans Health Admistration (VA)

John Smith is a 77 yr old navy veteran visiting his son Steve’s family in New York having travelled all the way from San Francisco, a 2500 mile journey. This is a particularly poignant Christmas as John suffered a major heart attack earlier in the year.

This morning, Steve found his father sweaty and disorientated. John was taken to the Emergency Department of the local VA Hospital. John was diagnosed with an infected ulcer in the right leg. The infection has spread to his blood stream. They looked up his electronic health record on the VA’s VistA system and instantly they had access to his whole medical record in San Francisco. They found out that in addition his recent heart attack, John also suffered from diet-controlled diabetes, kidney disease and high blood pressure. Indeed, John’s diabetic control has been poor; he has not collected his last 2 prescriptions and has been an inconsistent attender at outpatient clinics. His blood pressure has been difficult to control and his last recorded blood pressure (BP) was 165/85 mmHg.

John was not looking great. He look dehydrated and he was confused. His BP was 110/60 mmHg, pulse 110 bpm, Temp 38.5 C and his blood sugar was very high. He needed antibiotics right away. Steve said that he thinks that his father might have a penicillin allergy but cannot be sure. Thankfully, his doctors were able to confirm on the VistA system that this was untrue as he has been prescribed a course of penicillin earlier in the year for a mild chest infection and responded well to it.

To make a decision on which antibiotic to use, John’s doctor consulted their local antibiotic guidelines. After that, they looked back at John’s microbiological history on the Vista computer system. To their surprise, they found that a highly resistant strain of bacteria was found in John’s bloodstream earlier in the year when John had a similar infection. On the very same report, alternative antibiotics that can kill this bacteria was listed. The microbiologist on-call was consulted over the phone. Sitting at her home computer and using VistA, she recommended an alternative course of penicillin-related antibiotics tailored to John’s current illness.

These were commenced intravenously. John was transferred to the high dependency unit as even-though his blood pressure was ‘normal’, this was significantly lower than his usually high blood pressure. Over the next 24 hours, John slowly but surely improved. The blood test results from the day before confirmed the presence of the highly resistant strain of bacteria.

John did end up spending Christmas in the hospital but his family all visited. He was discharged on boxing day back to his son’s house. The intravenous course of antibiotics was continued at home by the community nurses. His doctors remotely monitored his treatment from the hospital using the Vista computer system. They also made minor adjustments to his diabetic medications.

Meanwhile in San Francisco, Dr Johnston, John’s primary care doctor has already been in contact with his colleagues in New York having been alerted by the VistA system that John has been admitted to hospital 2600 miles away. What John’s family did not realise was that John has also made a prior decision that in the event of his heart or breathing stopping, he did not want to be resuscitated. This was clearly documented on the VistA system with John’s signature electronically recorded. Thankfully, this document never needed to be consulted on this occasion.

Scenario 2: London, England, United Kingdom | NHS – National Health Service

John lives in the Newcastle, situated in north of England but is visiting his son’s family in London in the south. When Steve noticed his father was unwell, an ambulance was called and he was promptly admitted into of one of London’s most prestigious teaching hospitals.

Once again, a diagnosis of an infection in an ulcer spreading to the blood stream was promptly made.

As Steve thinks that his father is allergic to penicillin, a second choice antibiotic was used as recommended by the local antibiotic guidelines. Even though John’s blood pressure was much lower than his usual, the doctors did not have this information at hand; a blood pressure of 110/60 is the normal range for the general population. John received care on the standard medical ward.

Anti-diabetic treatment also commenced. The doctors did not know what medication John was usually on and his general practitioner (primary care practitioner) would not be open until 4 days later given the long Christmas weekend.

Over the next 24 hours, John deteriorated. His blood pressure continued to drop and he stopped passing urine. Appropriately, he was transferred to the high dependency unit. His blood results confirmed that he has an infection in his blood. Based on preliminary investigations, the antibiotics he is on should be effective. It was just too early to expect a response.

John continues to deteriorate. His is now in complete kidney failure. Fluid starts to accumulate in his lungs, depriving oxygen from vital organs such as his brain. He is transferred to intensive care unit (ICU) where his is put on a dialysis machine to take over the role of his kidneys and a breathing machine to oxygenate his blood. Blood results then revealed the highly resistant strain bacterial. His antibiotics was promptly changed. It is now 48 hours after his admission to hospital.

John suffers a cardiac arrest and after 10 mins of CPR and 3 cracked ribs later, the doctors successfully resuscitate him. Unfortunately his organs has taken another severe insult. The decreased blood supply to his brain has caused a stroke.

Over time, John starts to make a slow but steady improvement as the antibiotics start working. He spends a total of 10 days in intensive care. He lost 30% of his body weight and a lot of his muscle mass. He is in constant pain from his rib fractures. After discharge from ICU he was to spend another 30 days in hospital.

He finally felt to have recovered enough to be discharged back home to Newcastle in a wheelchair, carers 3 times a day, 20% lighter and a broken man psychologically. Dr Johnston, his GP, had no idea that John has been in hospital for the past 40 days until he was phoned up as part of the discharge process. When Dr Johnston visited John at home, he could hardly recognise him.

So, what are the differences and similarities between the two scenarios?

Similarities
Both scenarios took place in publicly funded heath systems in first world countries.
Both employ salaried and highly trained healthcare professionals doing the best they can for their patients.
Both encourage the use of locally agreed protocols and patient safety initiatives.

The difference?
Vista – the VA’s fully integrated Electronic Patient Record.
and
A patient with his health and dignity intact.

Find out more: http://nhsvista.net/

About the author

Dr Wai Keong Wong is a Haematologist in Training in London. Wai Keong is fellow on the NHS Medical Director Leadership and Management Scheme. He hopes to acquire skills that would allow him to drive up quality by aligning systems and processes which will remove barriers to safe, effective and personal healthcare – something he believes all patients deserve. He believes passionately that a fully integrated clinicians driven electronic patient record based on open standards is central to achieving this vision. He recently had the opportunity to visit a VA hospital whilst he was in the United States.

I am a junior doctor. I am trying to improve the working conditions in my hospital with a group of junior doctors, in order to provide better care in a more efficient manner so that we can spend more time with patients on their medical problems.

We feel that IT problems wasted a ridiculous amount of our time at work. A large part of our time is spent trying to log on to one of the many computers on each ward. Here it goes: Each member of staff has a username and password for Windows. Once you’re logged-in to Windows, anyone can access programmes for blood results, X-Rays and patient letters (through different programs which you need to log on again with different usernames and passwords) and the internet.

However, if you walk away and don’t log-out from windows (because you’re on a ward round and have to keep up the pace), the screen locks automatically and the next person who wants to quickly check blood results on their ward round can’t access that computer. That person can’t log you out. The only way to access the computer is to switch it off completely by cutting its power, waiting a minute or so, then switching it on again, then waiting while it re-boots another 2 minutes, then logging on. If you are already logged on somewhere else and nobody reboots the computer you are already logged on to then you can’t log on anywhere until you find the computer you are locked out of.

I reboot so many computers every single day on every ward at work, and so do all of my colleagues. I have never seen a patient or their relative sat at one of our computers trying to breach confidentiality. It just doesn’t happen and it can’t unless they have each program’s passwords anyway.

I brought this to the attention of the IT manager who booted me out of his office within minutes saying that wherever else I worked where they didn’t have this system must have been breaching the LAW of patient confidentiality. He was rude and an absolute brick wall to progress, typical NHS IT approach I’m sorry to say. I felt so demoralised and that is why I am bringing it to this group. I wonder if I should start by sitting on a ward for 12 hours and counting how many times each computer is rebooted on a normal work-day. Surely, for a start, this is not very good for the computers or the environment.

Thanks for your help.

A community of doctors and techies has since responded:-

Response 1 – Doctor with IT knowledge and skills:

http://support.microsoft.com/kb/314999
Get your Medical Director to argue that machines left logged in are the TRUE risk to Patient Confidentiality, as well as a preventable breach of the IT security policy. Better still, get your Caldicott guardian to do it.

Easily solved but inconveniences users like him who don’t have to HotDesk.

Response 2 – IT professional:

I was under the impression that smart cards had become mandatory across the nhs as per IG rules meaning users had to log out on moving from pc to pc. Maybe it’s just in my small part of the nhs…….

Response 3 – Junior Doctor with an interest in IT:

My advice is:-

Response 4 – Junior Doctor with IT knowledge and skills

I like the clicker idea, low tech but powerful. I’m sure it wouldn’t cost much to get a load of clickers. Arrange to meet with some fed up colleagues in the morning

What are the top 5 inefficiencies we want to count this week? Vote. Swap mobile numbers if haven’t already. Note who is working where. Agree ground rules for counting (Inc how will manage public relations e.g when patients/staff ask what you’re doing) Agree when/where will meet later that day.
Brief them on the inefficiency you will be counting that day
Meet at end of day to collect clickers and collate scores
Give feedback of scores to your group of quality improvement docs, chief exec, director of operations, director of IT (you all sign the letter and deliver by hand in a group). If still no change then there might be media interest in a group of junior docs having done this.
Also should write it up. By repeating the click count after stuff is, hopefully, fixed you have a nice QIPP project. Also demonstrates junior doc leadership.

Response 5 – Medical Physicist with an Interest in IT

At [removed], we have computers in communal clinical areas.  They have a screen saver installed, (I can find the name of the program we use if you require, but a quick example I found is http://windowsxp.mvps.org/winexit.htm), that logs the user out
after a period of inactivity.
We also have single sign on, (I can find the name of the program we use if you require).  When logged in it recognizes login screens of computer programs and websites and enters your logon credentials. Personally I am not very keen on the idea as it means that my password in plain text is stored on an IT server, and is automatically transfered to anything that looks like a legitimate program, but maybe I do not need to log in to things as often as you do.

Response 6 - Doctor with IT knowledge and skills (same author as Response 1)

Respectfully, no (to the idea of the clickers)
I thoroughly understand the need and satisfaction felt by physically doing something, but no. Compounding the waste of Clinical time is not professional behaviour and likely to be ineffectual.
Effort needs to be focused constructively and precisely to force change. You need to talk in terms that Directors understand, which is achieved by highlighting existing policy (as was done by the original author). Obviously the path of least resistance is current inaction by IT & you need to change that comfort zone.
This problem can be easily averted by the WinExit screensaver or a Group
Policy. Of course Single Sign-On using NHS Smartcards are ideal end-game but will
take time and significant motivation/investment to action.
IHMO, finding out how much time is wasted is barking up the wrong tree. But it is much, much easier than has assumed: Audit logs of log ins & log offs are always kept.
You just need to know the reboot time & the number of times a log off did not follow a log on. IT has this; getting them to share is another topic.
I was intending to communicate that generic accounts were tried and failed, i.e. not a viable solution.
The main complications are internet access whether to ePortfolios/eMedicine
(surmountable) or to Google/Wikipedia/YahooMail (insurmountable).
NHS Websites, hosted off the nhs.uk domain are also troublesome e.g.
http://prodigy.clarity.co.uk/home

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Open source software solutions also featured highly with a whole section and several sessions dedicated to it. I personally believe that the values of the open source movement aligns perfectly with the ethos of the medical profession; sharing best practice and welcoming criticism for the shared goal of continuous improvement. I recommend Carl’s publication for a detailed analysis of open source software in medicine.

There was also an opensource skunkworks were one of the challenges that was posted on the Openhealthcare UK google group was attempted by team at ScrapperWiki. This was to gather all the WHO Global alerts and response to outbreaks of disease world-wide. You can have a play with the data gathered here: https://scraperwiki.com/scrapers/who_outbreaks/

The EHI CCIO campaign is now truly in full swing with an announcement of the first 3 clinicians into this role and a personal endorsement from Andrew Lansley, Secretary of State for Health.

There is going to be a lot more on EHI Live 2011 here over the next few days and weeks but I would like to finish by highlighting the OpenEyes Project.

OpenEyes

OpenEyes is a collaborative, open source, project led by Moorfields Eye Hospital. Carl and I had the pleasure of meeting Mr Bill Aylward, Consultant Ophthalmologist and creator of OpenEyes who personally demonstrated the system to us. Our jaws dropped countless times as he showed us the capabilities of the system and how it truly enriched the doctors workflow and personalised the consent and shared decision making process with patients. I hope to be able to do a whole feature on this system with some personal insights from Mr Aylward.

Imagine this:-

1. Patient attends with a lesion around his eye.
2. A photograph is taken with an iphone.
3. The photograph is immediately transferred to the patient’s electronic patient record. (Yes. Really!)
4. The doctors annotates the picture on the computer screen.
5. The history and examination is recorded logically and electronically.
6. A diagnosis and management plan is entered.
7. A GP letter is ‘magically’ generated from all the above information and immediately emailed/ faxed.

This system is going live in a few weeks time at Moorfields and 13 satellite clinics.

You can read more about OpenEyes in this recent Guardian article. Oh yes, you can even collaborate on this project now and improve it as the source code is free for all to see.

Thank you EHI for a great event and thank you OpenEyes for showing what’s possible when great people work together to achieve great things. And this is just the beginning…..

My hospital has electronic ordering system for scans. Below is a representative process of ordering a CT Head Scan.

1. Find a free computer to log-on to.
2. Find the application icon for ordering.
3. Log-on again into that system.
4. Put in the patient hospital number.
5. Find the correct scan to pick.
6. Specify the consultant.
7. Specify my identity.
8. Specify my contact number.
9. Insert clinical reasoning behind the request for the scan.
10. Specify the urgency of the scan.
11. Find a printer and hope it works and has paper.
12. Print the completed form generated by the computer.
13. Walk out of the ward to find a radiology doctor to authorise the form.
14. Line-up whilst the radiologist deals with other requests.
15. Discuss the request with the radiologist who approves it by scribbling it on the printed form.
16. Take this form to the CT Scanning room.
17. Try to convince the staff in the CT Scanning room to prioritise scan.
18. Staff in the CT scanning room has to re-enter data into the radiology system.
19. Return to the patient on the ward to explain that we hope that the scan can be done urgently but we cannot say exactly when.
20. Frequently check on the patient throughout the day to see if the scan has been done.
21. Log-on frequently to check if report of the scan is ready.
22. Let the patient know the scan results and decide on what to do next.

If you are a non-health professional, I hope that this real-life example shocks you.

If you are a doctor, I hope this shocks you but my concern is that this scenario is so common throughout the country that it no longer has that effect.

My personal opinions are that this system:-

1. Takes away valuable time that I would like to spend with my patients to help them make sense of what is going on in an uncertain time of their lives.
2. Increases the anxiety of patients by introducing uncertainly about when they scan is going to be done and how long they have to wait for the results.
3. Exhausts unnecessary energy that could be better spent thinking about solving clinical problems and treating patients.
4. Does not realise the potential power of an electronic system.

This is just not good enough; not good enough for the doctors, not good enough for the patients and not good enough for the general public.

Something has to be done.