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

2. The NHS as a Business

3. 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.

4. 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.

5. 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.

6. 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

7. 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.

8. 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 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.

9. 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.

10. 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

11. 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

12. 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

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

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

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

16. Wide Area NHS Communications
Internet
Secure
Gateway
NHSnet Intranet

17. An Information Strategy for the
Information for Health
An Information Strategy for the
Modern NHS

18. 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

19. 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.

20. 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

21. 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

22. 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

29. 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.

30. Computers used in Treatment
Radiotherapy
Intensive Care
Patient Communication Aids
Protheses

31. 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.

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

33. Medical
Imaging

35. Computerised Tomography

41. Intracranial
haematoma

42. Renal
tumour

43. 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.

44. An MRI Scanner

45. Magnetic Resonance Imaging

48. Lumbar Spine

49. Knee
Anatomy

50. Baker’s
Cyst

51. Ultrasound Imaging

52. Ultrasound Imaging System

53. Pregnancy
Triplets

54. Liver carcinoma

55. Nuclear Medicine Imaging

56. Conventional
Radiography
Gamma Camera:
Pulmonary Embolism

57. THE END