Information Technology in Healthcare Dr Keith Boardman Director of Computer & Network Services University Hospitals Coventry & Warwickshire NHS Trust

The NHS as a Business

National Health Service Formed in 1948 Employs 1 million people 500 health authorities Costs £37 billion Treats 8.4 million in-patients a year About 3 million day-cases a year 40 million out-patient attendances 30,000 GPs Before exploring the Walsgrave Trust’s stance on GP Links it is relevant to position the WalsgraveTrust. First of all we are a large acute Trust with a contract income of some £116M. There are 1246 beds - a number that changes as we migrate services from two sites four miles apart onto a single site. Most importantly we are a high tech’ hospital with just about all the main acute specialist services such as: Cardiothoracic surgery Neurosurgery Renal & Transplantation services Neonatology Oncology - with Radiotherapy and diagnostic services such as CT and MRI scanning Another relevant feature is that approximately 98% of Coventry residents obtain their acute healthcare from Walsgrave. We are a compact or tight natural community with a relatively small cross-boundary flow. However our specialist services cover a large geographical territory and amounts to some 18% of our income.

UHCW NHS Trust Acute Trust with 1246 beds 11 Regional Specialities Meets 98% of Coventry & Rugby acute healthcare needs Contract Income £200M approx. 6000 employees Before exploring the Walsgrave Trust’s stance on GP Links it is relevant to position the WalsgraveTrust. First of all we are a large acute Trust with a contract income of some £116M. There are 1246 beds - a number that changes as we migrate services from two sites four miles apart onto a single site. Most importantly we are a high tech’ hospital with just about all the main acute specialist services such as: Cardiothoracic surgery Neurosurgery Renal & Transplantation services Neonatology Oncology - with Radiotherapy and diagnostic services such as CT and MRI scanning Another relevant feature is that approximately 98% of Coventry residents obtain their acute healthcare from Walsgrave. We are a compact or tight natural community with a relatively small cross-boundary flow. However our specialist services cover a large geographical territory and amounts to some 18% of our income.

General Specilaties Regional Specialties Urology Cardiac Surgery General Surgery Ear Nose & Throat Ophthalmology Oral Surgery Orthopaedics Rheumatology Dermatology General Medicine GP Maternity Gynaecology Special Care Baby Unit Paediatrics Obstetrics Cardiac Surgery Thoracic Surgery Cardiology Renal Transplantation Renal Dialysis Neurology Neurosurgery Radiotherapy Bone Marrow Transplantation Haemophilia Services Neonatal Intensive Care Our IT infrastructureis also relevant to our links strategy. Like most health organisations we have a mix of what at the time were considered best of breed systems. Examples include: GTE Hospital Information Support System Telepath pathology system Cortex pharmacy system Clinical Computing Renal system In-house Oncology system There is a need for system integration on two counts - there are both internal & external business drivers - a strong internal one is to obtain Cancer Centre status, and externally that of GP links. Perhaps a scenario with respect to cancer information flows illustrates the need for systems’ integration: (1) A patient may be self referred - a GP interaction, or from a screening process such as through breast screening or cervical cytology. (2) There will be a referral to hospital - resulting most likely in pathology and radiological tests, and of course registration on HISS. (3) If an in-patient episode results - there may be interactions with surgery, radiotherapy, haematology, pharmacy. In our community this could produce interactions with 9 systems.

Activity Levels In-patient attendances - 90,000 Out-patient attendances - 306,000 Emergency assessments - 27,000 Accident Dept attendances - 103,000 Pathology requests - 865,000 Radiology Examinations - 207,000 MRI & CT Scanning - 13,000 Patient meals - 1,400,000 Staff meals - 744,000

Computers in Healthcare Key application areas: Information Management Treatment Diagnosis How do we progress these issues and in particular systems integration? The slide illustrates our approach. Within the Trust we are implementing what we call our Universal Information Distributor (UID) or as sometimes known generically as an Interface Engine. We have chosen the ICS TALK product running under Microsoft NT - NT as an important component of the Trust’s IT strategy. ICS is one of the participants in the Virtual Health Servce exhibition here at EHI 96. This provides a method of linking internal Trust systems and most importantly the sharing of the Master Patient Index on our HISS with other systems. In this way we meet a fundamental requirement to capture data once and share it. This we believe is the key to clinical systems integration, and so for services such as Oncology we see the possibility of systems integration to facilitate relevant data sharing through one workstation at the point of health care delivery. Once such sharing and data transfers are in place it is a relatively easy step to put a gateway to the outside world ... for GP links, and by using the appropriate EDI software set .. to Racal or BT Syntegra as required.

Information Management Hospital Administration Systems Community & GP Systems Clinical Information Systems Business Systems In summary the benefits are indicated in this slide. Interfaces are expensive and the UID approach means that only one interface is required per system. In a sense the lesser of two evils. Our HISS experience, admittedly with a US supplier, is they can amount to 5 or 6 figure sums inclusive of indirect staff time costs. Hence the important benefit of only one per system, which also assists the individual replacement of discrete systems as when deemed appropriate. Data integrity is improved by timely data entry once which is then available for sharing for ancillary systems. We have used E-Mail very successfully for several years using IBM’s OfficeVision product. The UID and Microsoft’s BackOffice & Exchange products gives us a migration path to more modern Windows based products. For example the Microsoft SNA gateway works well with our IBM AS400 environment. Clearly this level of integration also provides the vehicle for linkages to the outside and in particular GPs. In summary we feel the approach has an overall lower cost and provides a pragmatic approach to moving forward.

Hospital Information Systems A HIS meets the real-time operational information needs of health professionals to deliver care to patients, whilst also providing accurate and timely information for management purposes. Of course there are drawbacks and not a bed of roses. The development of interfaces, known as Application Program Interfaces, although much reduced, still costs money. One of the most complex issues centre around the maintenance function and that of data ownership and data standards. We have established a Data Standards Group with the specific remit to check and reconsile data entities across individual systems. Data ownership is about which systems are allowed to update which and by whom? Once ownership has been decided it is relatively easy to maintain data synchronisation. Data synchronisation itself is about ensuring that similar data entities across discrete systems are the same at the same moment in time. An example might be a clients’ address - the patient has (correctly) two addresses but representing different moments in time. It is important to ensure that once a new address has been identified it is made available to all relevant systems - the principles of single data capture and sharing. Of course there is still a maintenance function but we believe this is containable because in effect the UID is a toolset which enables rapid development when specific systems data specifications are changed.

HIS Benefits Improved care and delivery of services provided to patients Reduced administrative work Better information for resource management So what is the way forward - there are clearly plenty of potential barriers? I think I have elaborated on the first two points, and frankly we would, as a Trust, move down this road with or without GP links. The issue about de facto standards is important. We seem to spend inordinate amounts of time (measured in years) discussing, piloting, consulting, more piloting, and reviewing messages etc. All very admirable but should we not be more focused and establish the basic messages with a higher sense of urgency. We know we work in a complex industry but when I compare how the finance, insurance and travel industries have addressed similar issues we do begin to look pathetic. Having said that it is further frustrating to find most energy is being put into administrative applications - to date has an individual patient directly benefited from any of this? The cajoling of GP suppliers is easier said than done. I don’t blame them for the histrionics - we will get there, but really a three-line whip is required to pump prime and stimulate the GP systems marketplace. One can't help feeling that the distractions of political pressures and the need to maintain obsolete systems is impeding progress. At Walsgrave business cases are not the issue, we have not been able to spend budgets because GPs cannot get connected at the application level. An urgent refocus is required to bring clinical flows on stream. Finally whilst one wants to end on a positive note I feel obliged to comment on ROME (Roll-Out of Messaging Environment) by BT Syntegra. If you have followed the media on this you will be probably be sceptical about this approach as it does not address the nub of the problem. It will not solve the impasse, because the real systems integration issues are not resolved. Finally reference to EDIFACT messages in the NHS

HIS Functional areas (used by 1500 staff) Patient Administration Admissions, Discharges and Transfers Accident & Emergency Maternity Operating Theatres Professions Allied to Medicine Case Note Tracking Contracting & Billing

HIS Computer System: HP9000/K460 running UNIX 2 G Byte RAM 100 G Byte disk storage (RAID) 128 V24 ports IEEE 10/100 MHz Ethernet Cartridge Magnetic Tape DLT Magnetic Tape

Clinical Information Systems Intranet & Internet Clinical Information System Pathology Radiology Clinical Documentation

Computer Systems Overview HIS HP9000 Community HP 9000 Breast Scr’ HP 9000 MIS General E-Mail Local Area Network (with ATM backbone) PC Client Access Pathology RS6000 Pharmacy RS6000 Radiology Sun Renal HP 9000

DATA INTEGRATION PC Client Access Pathology System Radiology HIS Interface Engine Clinical System (Data Warehouse) PC Client Access Local Area Network (with ATM backbone)

Wide Area NHS Communications Internet Secure Gateway NHSnet Intranet

An Information Strategy for the Information for Health An Information Strategy for the Modern NHS 1998-2005

Top level commitment “The challenge for the NHS is to harness the information revolution and use it to benefit patients”. Rt. Hon. Tony Blair All Our Tomorrows Conference 2 July 1998

Purpose of the strategy . . . . to put in place over the next seven years the people, the resources, the culture and the processes necessary to ensure NHS clinicians and managers have the information needed to support the core purpose of the NHS. And to ensure the public and patients have a range of quality information easily accessible about health and health services.

Treatment and care Primary care EHR Public Patients Healthcare professionals Managers Knowledge for Public health Clinical Governance Health Improvement Programme Performance management Analysis Social records NHS Trust EPR

Defining electronic records Electronic Patient Record - a record of periodic care provided by one institution, typically an acute hospital Electronic Health Record - the concept of a longitudinal record of a patient’s health and healthcare to combine information from primary healthcare with periodic care from other institutions

4 Key Pieces of the Strategy Better Practice Systems + Electronic Health Record ( EHR ) INFRASTRUCTURE (wires,security,standards) Better Hospital Systems + Electronic Patient Record ( EPR ) National Electronic Library of Health ( NELH ) 4 Key Pieces of the Strategy

Computers in Healthcare Key application areas: Information Management Treatment Diagnosis How do we progress these issues and in particular systems integration? The slide illustrates our approach. Within the Trust we are implementing what we call our Universal Information Distributor (UID) or as sometimes known generically as an Interface Engine. We have chosen the ICS TALK product running under Microsoft NT - NT as an important component of the Trust’s IT strategy. ICS is one of the participants in the Virtual Health Servce exhibition here at EHI 96. This provides a method of linking internal Trust systems and most importantly the sharing of the Master Patient Index on our HISS with other systems. In this way we meet a fundamental requirement to capture data once and share it. This we believe is the key to clinical systems integration, and so for services such as Oncology we see the possibility of systems integration to facilitate relevant data sharing through one workstation at the point of health care delivery. Once such sharing and data transfers are in place it is a relatively easy step to put a gateway to the outside world ... for GP links, and by using the appropriate EDI software set .. to Racal or BT Syntegra as required.

Computers used in Treatment Radiotherapy Intensive Care Patient Communication Aids Protheses

Computers in Healthcare Key application areas: Information Management Treatment Diagnosis How do we progress these issues and in particular systems integration? The slide illustrates our approach. Within the Trust we are implementing what we call our Universal Information Distributor (UID) or as sometimes known generically as an Interface Engine. We have chosen the ICS TALK product running under Microsoft NT - NT as an important component of the Trust’s IT strategy. ICS is one of the participants in the Virtual Health Servce exhibition here at EHI 96. This provides a method of linking internal Trust systems and most importantly the sharing of the Master Patient Index on our HISS with other systems. In this way we meet a fundamental requirement to capture data once and share it. This we believe is the key to clinical systems integration, and so for services such as Oncology we see the possibility of systems integration to facilitate relevant data sharing through one workstation at the point of health care delivery. Once such sharing and data transfers are in place it is a relatively easy step to put a gateway to the outside world ... for GP links, and by using the appropriate EDI software set .. to Racal or BT Syntegra as required.

Computers used in Diagnosis Computerised Tomography Magnetic Resonance Imaging Ultrasonics Radioisotope Imaging

Medical Imaging

Computerised Tomography

Intracranial haematoma

Renal tumour

Magnetic Resonance Imaging Protons in a magnetic field have a microscopic magnetization and act like tiny toy tops that wobble as they spin. The rate of the wobbling or precession is the resonant or Larmor frequency. In the magnetic field of an MRI scanner there is approximately the same number of proton nuclei aligned with the main magnetic field as counter-aligned. On a macroscopic level, exposure of an object or person to RF radiation at the Larmor frequency, causes the net magnetization to spiral away from the static field. Relaxation is the process whereby nuclear magnetization returns to its resting state following a perturbation, such as by an RF pulse.

An MRI Scanner

Magnetic Resonance Imaging

Lumbar Spine

Knee Anatomy

Baker’s Cyst

Ultrasound Imaging

Ultrasound Imaging System

Pregnancy Triplets

Liver carcinoma

Nuclear Medicine Imaging

Conventional Radiography Gamma Camera: Pulmonary Embolism

THE END