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20190232 The Doctor - Issue 9 May 2019

Doctors are let down every day by poor IT in the health service. Outdated software and basic delays in accessing records make a mockery of modernisation plans. Tim Tonkin looks for ways out of the jumble

As with death and taxes, IT problems are an inescapable aspect of modern life.

However, while the sum total of IT problems for many amounts to little more than the slow streaming of a TV box set, the consequences for doctors – whose day-to-day professional lives often depend on functioning IT – can be far more serious.

A survey carried out last year by the BMA found that nearly a quarter of doctors taking part said they felt the IT systems in their workplaces were not fit for purpose.

Aspects of technology singled out include the electronic health record and medical record, described as inadequate by 48 and 57 per cent respectively, with 43 per cent saying the same of electronic prescribing and 40 per cent of their e-referrals system.

‘I have lost hours of time sorting out my IT problems since starting my core trainee 2 post in August,’ wrote one junior doctor responding to the survey. ‘I’ve stayed late on call when I’ve lost all my work on the system and had to rewrite notes. I had no personal file and therefore no ability to save any work on a hospital PC for over two weeks.’

Thirty-two per cent of doctors told the survey that they rarely had access to the requisite IT equipment to perform their jobs to the best of their abilities, with 56 per cent saying poor IT significantly increased their day-to-day workload.

 

Access denied

Poor IT causes more than irritation. More than a third of doctors said it had a significant effect on their workplace stress levels.

‘My email was suddenly closed down leading to no access to patients’ blood results on an acute ward,’ reported another hospital doctor to the survey.

‘I have lost another two hours today unable to access a patient notes system and therefore delay in uploading very important ward-round notes and clinical plans. I am at my wits’ end.’

The causes of deficient health service IT span a number of areas, with outdated software and hardware cited by 63 per cent of those taking part in the BMA’s survey. However, the greatest culprits include having to work with too many different systems (74 per cent) – many of which are not interoperable and struggle to talk to each other (65 per cent).

‘I’ve stayed late on call when I’ve lost all my work on the system and had to re-write notes’

It is on the back of these findings that the BMA has produced a new report, Technology, infrastructure and data supporting NHS staff, outlining how deficiencies with IT infrastructure are adding to workload and even compromising patient care.

Among its recommendations for improving the state of IT is an upgrade of all basic IT hardware to a nationally recommended standard, as well as providing fully functioning wi-fi and 5G to be made standard across the NHS.

Doncaster GP David Coleman (pictured below) understands all too well the consequences of the basics going wrong when it comes to IT.

As a partner at the Conisbrough Group Practice, he has had to contend with a raft of issues relating to IT on a near daily basis. One of these included a long-running problem with his practice’s clinical records system, EMIS, which is responsible for everything from appointment booking to hospital test results.

‘The primary problem we’ve been having over the past 12 months – which I have to say has improved after much back and forth – is reliability of the clinical connection,’ he says.

20190232 The Doctor - Issue 9 May 2019

‘We were having lots of problems with our system crashing, being unresponsive and having the “spinning wheel of death”.’

 

Software downgrade

Dr Coleman says instances of poor interoperability can even occur between pieces of workplace software that were supposed to work in tandem. To this end he cites his own practice’s experiences relating to the unintended consequences of an upgrade to their electronic documents management system, Docman.

‘We were told [by the CCG (clinical commissioning group)] that we were going to get this shiny, new piece of software [Docman 10] and it was going to be web based,’ he says.

‘Pretty much straight away we started running into a lot of problems… it was a lot clunkier and sometimes did not work. We thought it was maybe teething problems… but things went from bad to worse.’

The upgrade, which Dr Coleman has found to be incompatible with the EMIS system, meant that he and his colleagues continued to struggle to access more than 200,000 pieces of medical correspondence, something that places a considerable additional burden on his team.

‘Rather than being a timesaver and a useful tool it was actually an obstacle,’ he says.

‘I have lost two hours today unable to access a patient notes system’

A spokesperson for the company responsible for Docman declined to comment.

Crucial to understanding the health service’s patchy relationship with IT, is understanding the legacy of the early 2000’s National Programme for IT.

Launched in 2002 and commanding a budget of more than £11bn, the programme sought to revolutionise data sharing in the NHS by creating an integrated electronic care record for every patient designed to be easily shared across all parts of the health service.

Tenders for the delivery of services were put out across the five regional clusters of NHS England, with contracts being awarded to different providers in different areas.

Disputes over these contracts and the subsequent delays in the rollout led to many of the programme’s core objectives falling behind schedule and exceeding the original budget.

In 2010 the newly formed coalition government announced that the programme would no longer be run on a centralised basis, adding that ‘decision making and responsibility’ around IT development would instead be driven at local levels.

 

Lack of consultation

A report published by the public accounts committee that same year observed that the dismantling of the programme had resulted in the onus of developing IT systems compatible with those introduced by the programme falling on individual trusts, meaning that ‘different parts of the country will have different systems’.

It also noted how much of the waste and pitfalls experienced by the programme could have been avoided had the health professionals destined to use the systems been consulted from the outset.

Bristol consultant oncologist Adam Dangoor (pictured below) understands the frustrations posed by poor IT services, as well as the potential benefits good use of digitisation and technology present for healthcare.

For the past two years, Dr Dangoor has been the joint CCIO (chief clinical information officer) at University Hospitals Bristol NHS Trust, a post which sees him liaise between the trust’s IT department and clinical workforce.

20190232 The Doctor - Issue 9 May 2019

Like many of the doctors responding to the BMA’s survey, he cites issues such as having to navigate multiple, separate software programmes and lack of interconnectivity and data sharing between different trusts.

‘In clinic I’ve sometimes had up to 17 windows open on my computer including three different PAC [picture archiving and communication] systems for different trusts, test results systems, a dictation system for patient letters, and chemotherapy prescribing software,’ he says.

‘There are multiple different passwords for all the systems you are using at any one time.

‘[Another] one of the problems is that if we’re referred patients from outside [our trust] it’s quite difficult to look at their imaging if it’s from another centre. We either have to keep active passwords for the host hospital PAC system or have the images sent across electronically which means someone has to ring that hospital and ask for the images to be transferred to our system.’

 

Unexpected benefits

Despite the existing challenges posed by IT, Dr Dangoor says it is important to acknowledge some of the advances that either had been or were in the process of being made.

‘Clinicians should note that, despite the challenges, we are already at the stage where we can sit at a computer and access a whole range of information about our patients from vital signs, blood results, medications, radiology images and clinical notes.

‘These are amazingly useful for consultants on call who can find out what is happening with their patients before even visiting the ward.

‘Going forward, electronic records will be based on directly entering data, as GPs already do. This will produce records that can then be searched and analysed to improve care which is much more powerful. We’re not there yet, but we’re making steady progress.’

Dr Dangoor believes improvements to IT would most likely be a ‘bottom-up’ endeavour, with regional health services, trusts and clinicians themselves taking a crucial role in development but says that there is still a place for an overarching, national approach.

‘Nationally we have to have open standards and data-sharing agreements,’ he adds.

‘NHSX and NHS Digital need to make sure that we have common standards; interoperability is key. At the moment data is in silos and it is not easy for organisations to share it, even between internal software systems.’

 

Progress promise

At a glance, the noises coming out of the Department of Health with regard to IT and the importance of interoperability and getting the basics right, appear to be encouraging.

Health secretary Matt Hancock is on record as saying he wants the NHS to become ‘the most technologically advanced health and care system in the world’.

He has also accepted that rectifying existing deficiencies in NHS IT is essential ahead of any future technological enhancements, and has sought to emphasise how the Government’s latest vision for NHS IT – ‘The future of healthcare’ – will not adopt the kind of top-down approach seen in the national programme.

There are, however, areas of disagreement and concern with aspects of Mr Hancock’s vision for IT, with his championing of the ‘GP at Hand’ mobile app being a case in point.

Launched in 2016, GP at Hand began life as a collaboration between private health firm Babylon and the Dr S Jefferies and Partners practice in south-west London.

Using mobile-based technology and artificial intelligence, the app is designed to allow patients 24/7 access to consultations via a text-based chat bot or video calls with a GP.

The area’s CCG has warned that the list-size surge associated with GP at Hand has led to ‘increasing costs’ that, unless mitigated, could lead to other health and care services provided by the CCG being jeopardised.

 

Get the basics right

Despite these concerns, Mr Hancock has described GP at Hand as a revolutionary service that he hopes to see extended, and has also strongly endorsed the development and use of artificial intelligence in providing healthcare.

The BMA, however, has warned that the promotion of new initiatives such as video conferencing should not come at the expense of existing ‘place-based care’ and that investment in GP practice IT infrastructure are pre-requisite to any such advance.

‘In clinic I’ve sometimes had up to 17 windows open on my computer’

Investment in the basics and avoiding over-reliance on emerging technology is an outlook shared by Bengi Beyzade (pictured below), GP partner at Clerkenwell Medical Practice and clinical IT lead for the Islington GP Federation.

Dr Beyzade warns that the mishandling of the national programme left a legacy of mistrust among many doctors when it comes to government pronouncements on IT. He is wary of the drive to promote emerging digital technologies as a cure-all for the health service’s existing IT shortcomings.

‘The term AI is misused,’ he says.

20190232 The Doctor - Issue 9 May 2019

‘We look at AI and we look at our sci-fi films and think of an intelligent, learning computer. Is that really the AI they’re talking about now? It’s generally a programmed algorithm that doesn’t seem to learn for itself.

‘I think it’s disappointing that they are being sold as a magic bullet now. They do have value but if false promises are being thrown out there just for us to be let down, it will feed the lack of faith we have in government when they push IT on us.’

Dr Beyzade says that while IT has always been a part of his general practice career, its functions are now so integral that when problems occur, everything else could come grinding to a halt.

‘IT has always been there [in general practice] but has become more and more embedded, and in order to continue your daily functions, you’re more and more dependent on it,’ he says.

‘Previously if you had an IT failure, you could just about get on and see a patient. There’s so much safety in place now that’s wrapped around IT in terms of access to educational resources like the British National Formulary or guidance on how to manage certain conditions that if you don’t have access to that resource [as a GP] you can’t function.’

 

The right course

BMA council chair Chaand Nagpaul says getting IT right is fundamental to the BMA’s vision for a technologically enhanced future NHS.

In a letter to the health secretary [Dr Nagpaul] sent on 4 April, said the Government must prioritise investment aimed at rectifying the existing IT deficiencies in the health service, ahead of new and emerging digital technologies.

‘Basic hardware needs to be upgraded – doctors and clinicians should not have to take time out from caring for patients to fix malfunctioning systems.

‘Alongside good quality, interoperable IT – and the funding required to make this happen... national standards, patient experience, and staff education and training must all be considered as key factors to achieving a digital transformation for patients and the NHS workforce.’ 

 

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