Royal Alexandra Cardiovascular Health
Electronic Links (RACHEL)
Application for funding
under the call for Proposals
from the Scottish Office
May 1999
Argyle & Clyde Acute Hospitals NHS Trust
Corsebar Road
Paisley
Renfrewshire PA2 9PN
Contacts
Dr Iain Findlay
I.findlay@rah.scot.nhs.uk
0141 887 9111
Mark McPhail
M.mcphail@rah.scot.nhs.uk
0141 887 9111
Mark Salveta
Mark.Salveta@isd.csa.scot.nhs.uk
0131 551 8556
1
Contents
1. Executive Summary
2. Project Structure
3. Strategic Context
4. Background
5. Objectives
Objectives & Benefit Criteria
6. Risk Analysis
7. Preferred Option
8. Risk Avoidance Strategy
Appendices
i-iii
Forms from present system
iv
Gartner Group Market Intelligence report
v
List of Cardiology depts
vi
List of local GPs already connected
vii
Newspaper/Hospital Doctor articles
viii
Report of a visit to the Royal Alexandra Hospital (Paisley) to assess the Coronary
Care Carenet Project
2
1. Executive Summary
This Business Case sets out a proposal for funding which will establish in line
with Government policy a shared clinical record in the first instance for
cardiology Patients. The initial agreement to proceed from the Scottish Office
under the telemedicine initiative has resulted in this document.
The RACHEL Project will seek to use telemedicine technologies and
techniques to support the delivery of cardiology services from the Royal
Alexandra Hospital (RAH), Paisley. In particular it will address the problems
associated with information sharing across professional and organisational
boundaries.
It will seek to create a model of integration between Primary, Secondary and
Tertiary centres for one speciality which can be repeated for other specialities.
It will also seek to alleviate the current administrative burden on clinical,
nursing and administrative staff by providing a shared electronic information
infrastructure. The project will fully exploit the telecommunications
infrastructure being implemented by the Scottish Office (NHS Net) and will
draw on the latest information available to support evidence based practice. It
will also fit with the NHSiS IT Strategy and seek to develop a model for
cardiology care which can be repeated across Scotland linking with CHI, the
proposed GP Gateway and the Hospital level Gateway.
The proposal builds on work already undertaken in establishing the CareNet system in RAH
with links to eight local GP practices. This proposal aims to:
•
support the delivery of electronic discharge summaries to the participating GP practices,
•
provide access to evidence based guidelines
•
enable GPs to refer patients for appointments electronically
•
facilitate information exchange between the participating organisations.
The project will also include linkage to the Hospital’s MUSE system (which electronically
stores ECG traces) to make them available to GPs, hospital staff when off-site, and, in time,
other hospitals. This may be particularly useful when a patient is admitted with chest pain and
has a previous cardiac history; electronic data retrieval may allow an immediate comparison
with the previous ECGs and could assist in decisions about thrombolysis treatment. A part of
this proposal will be to look at the options open to other centres to make their ECGs available
to all NHSiS Organisations.
The preferred option is the continued development of the current system, either independently
or as a module of GPASS. Our goal is to achieve maximum benefit for the NHSiS, in line with
the White Paper “Designed To Care” and the NHSiS IT Strategy.
This table represents the options considered
Option
Total Cost
NPV
Benefit Score
Risk Score
A
£0.00
£0.00
0
300,000
3
Do nothing
B
Highest Risk
£1,096,000
£1,041,189
915
rd
Develop New
System
C
3 Highest
Risk
£832,000
£788,685
883
Develop Present
Systems
D
209,000
110,500
Lowest risk
£691,000
£655,515
860
Wait for
Integration and
develop CCU
System
262,000
nd
2 highest
Risk
Option A Do Nothing. This will not achieve the White Paper Targets
Option B Develop System from scratch. This the most expensive option and although it
will make the White Paper Targets is unlikely to do so in the required timescales.
Option C Build upon the CCU/carenet project. represents least risk whiles making the
White Paper targets and the benefits they will deliver. This option includes the costs required
to develop the necessary technologies.
Option D Wait for Integration Technologies to be established. This is an option that will
not meet the White Paper timescales, is high on risk and does not include the costs of
developing the technologies required.
Option C will deliver the following benefits once the proposed system has
been installed:•
provision of improvements in the delivery of healthcare to patients through
the application of continuously updated best practice evidence based
medicine leading to improved Quality-Adjusted Life Years
•
development of integrated care pathways through the combination of
medical and nursing notes
•
off-site consultant interpretation of ECGs to ensure that all patients receive
thrombolytic therapy when appropriate
•
provision of up to date integrated shared clinical records on cardiology
patients in primary, secondary and tertiary health environments
•
implementation of a simplified but comprehensive electronic referral
process leading to more appropriate referrals
•
facilitation of improvements in the management of patients with chest pain
and improvement in the appropriateness of care for patients with acute
coronary syndromes
4
•
use of CHI to uniquely identify all patients on the system
•
rapid delivery of outcomes of out-patient appointments and provision of
detailed test results including multi-media test results
•
impetus for further investment in telemedicine applications (for example in
respiratory medicine and diabetes)
•
clinical governance through the facilitation of clinical audit and outcome
analysis
•
facilitation of accurate Clinical coding
•
alerts to GPs indicating acute admission of their patients to Hospital
•
realisation of improvements in hospital resource utilisation
•
provision of improvements in training and professional development
5
2. Project Structure
Structure
The proposed project has three main phases, and provides an opportunity to evaluate
success at the end of each phase.
Phase 1:
1. build upon the existing system and test the technology in new areas:
Further work will be undertaken to incorporate clinical governance guidelines and
protocols into the system. In many ways this is the most important clinical part of
this project.
2. Cardiology Image Transfer:
We will achieve the electronic transmission of ECGs outside normal working
hours from A+E to a consultant cardiologist for a definitive opinion in cases of
diagnostic uncertainty.
3. Intelligent decision supports systems
In the pilot phase (see summary) we have installed in A+E a computer linked to
the hospital network/CARENET. Data collected on the admission chest pain form
will be entered electronically. This live data entry taken with the enhanced ECG
diagnostic accuracy will be evaluated with a clinical decision support system
developed by Professor Lee Kennedy
4. Establish a clinical review mechanism to monitor the project
5. Development and integration with GPASS of the current CCU database/ Carenet system.
GPASS will be the clinical database used by the majority of GPs in NHSiS. The
development of a cardiology EPR would be facilitated by seamless transfer of
data between our hospital systems and GPASS. We are exploring such a link
between GPASS and CARENET. There is a strong commitment to this
integration of primary and secondary care information systems by the
cardiologists at the RAH.
6. The further development and evaluation of a common EPR (Electronic Patient Record
)covering the clinical and nursing record in co-operation with other cardiac centres.
It is likely that other cardiac centres would want to modify any hospital-based
database system for their own purpose. This will apply equally to medical and
nursing staff. However, it is imperative that there is a minimum common dataset
of useful clinical information that will be required by all centres. In this part of the
Rachel Project we will look at other database systems (such as Minerva) and
ensure that similar data definitions are used.
7. The evaluation of the immediate discharge data set currently transmitted to GPs and the
further development of the standard discharge letter as per the SIGN guidelines.
8. The testing and improvement of the resilience of the System
9. The pilot running of the enhanced system resulting from the early stages of the RACHEL
project in another Hospital.
Inverclyde Royal Infirmary is one of the hospitals in the new Argyll and Clyde
Acute Hospital Trust. We propose that this hospital be a sister site for this
6
project. This will have the advantage of being part of the same IT strategy as the
RAH.
10. Develop link to hospital order comms systems labs, pharmacy etc
11. Linking to an electronic drug formulary
Linkage of the electronic prescribing system to an electronic forumarly, such as
the electronic B.N.F., confers the advantages of on-line access to correct
prescribing information and automatic alerts for drug interactions and
contraindications. We will seek to link our electronic prescribing system either
with e-BNF, EMISS or with the formulary already incorporated within GPASS.
12. The creation of a link with CHI through the HBs chosen method currently being explored
in a separate project
13. Roll out of system to all GPs in HB.
14. The development of a diabetes version of the system to test the commonality between the
two specialities.
Phase 2
The second phase will set up a multidisciplinary and NHSiS wide team to work on the
evidence of phase 1 and to:
1. Develop the system to work through the GP Gateway to GPASS
2. Develop a method of allowing GPs to refer suitable patients for Hospital
out-patient appointments electronically
3. Establish a standard method of transferring cardiology images from the
hospital to GPs and between hospitals electronically
4. Establish the means to encode data within discharge summaries and to
explore methods of mapping between different coding systems (i.e. ICD10
to Read and vice versa)
5. Create an application which can be rolled out to other CCUs
6. Establish a standard that other CCU systems must meet in order to
become part of the integrated system
7. Establish a support mechanism for the CCU System from an outside or
inside source depending on likely take up of system.
Phase 3
The third phase will:
1. Establish a program of linking other cardiology depts either with their own
systems or the new system resulting from the RACHEL project to the
standard GP Gateway/Hospital Gateway Cardiology interface
7
2. Deliver training to GPs and other medical staff on the standard Gateways
3. Implement a system which will where “clinically appropriate”, allow GPs to
electronically refer patients to hospital for out-patient appointments.
4. Provide a support mechanism for the new system
5. Establish an on-line database of most recent patient ECGs available to
clinical staff at primary, secondary and tertiary healthcare centres.
Project Management
The project will be managed using the PRINCE II project management
methodology and a risk analysis is detailed within this proposal.
Cost
The cost of the proposed project will be £832,000
8
3. Strategic Context
Since the publication of the White Paper “Designed To Care” the NHSiS has moved to
establish the necessary IT infrastructure to allow the White Paper objectives to be achieved.
Quoting directly:
New technology that links GP’s surgeries to any specialist centre in the country.
Our commitment to clinical effectiveness is designed to ensure that wherever patients make
use of the services of the NHS they receive the highest quality care. We will create a
seamless service which gives patients continuity of care from GP through hospital to
rehabilitation.
This can also carry the output of diagnostic machinery, such as radiological images. Coordination of care can also be improved through speeding up the processes of transferring
records, transmitting test results and making appointments.
To the patient, the NHS is a single entity geared to providing a co-ordinated and
comprehensive care service. Patients expect to move from general practice to hospital, ward
to ward, and hospital to community with ease. Information related to them should move with
equal ease, but it does not always do so. As a result, patients can become by default the
means of transporting information. The Government wish to change this. A safe flow of
information about patients between GPs, hospitals, and other healthcare professionals is
needed, and new technology is enabling them to share it, under professionally agreed
safeguards. We intend to accelerate this process.
One of the first steps is to use the same number to identify patients wherever they are
treated, and the Community Health Index number creates this opportunity. This unique patient
identifier gives the NHS the means by which we can securely bring together the right
information about a patient at the right time and place. Over the next two years we will ensure
that all Health Service systems are able to use this number. We will continue to work with
healthcare professionals through their Royal Colleges to define the key sets of information
which need to be communicated. As well as referral and discharge letters, key information
items are being specified for particular conditions and diseases so as to help ensure best
clinical practice. The computer systems which will deliver this information are also important.
They will first and foremost be designed for use by healthcare professionals in carrying out
their clinical tasks. For example, ordering blood tests by electronic links is quicker and more
reliable than filling in forms; and getting the results back on that same screen is not only just
as useful, but quicker. To achieve these links, the whole of the NHS in Scotland will be linked
to secure health service telecommunications systems over the coming year to ensure there
are no obstacles in the way of assembling the right information.
The Government's objective is to use technology to promote a seamless pattern of care. With
this in mind we have decided to fund a number of demonstration projects focusing on two
issues of current concern to patients:
the establishment of one-stop clinics where all tests are carried out in a single visit, and
results and diagnosis, where possible, are available the same day. We will set a timetable to
ensure that this practice becomes widespread within the NHS in Scotland; during 1998 we
will electronically link up every GP surgery in Scotland. By the year 2002 patients will know
the date of hospital appointments when they leave the surgery.
The Government's intentions emphasise the role of clinicians and patients in the design of
services, and encourage the integration of service delivery in a seamless pattern across the
interface between primary, secondary and tertiary care.
“We will also stand by our pledge that this will be a better NHS. That is why we are launching
a series of initiatives to improve service delivery in this White Paper. These include:
9
• one stop clinics to provide tests, results and diagnosis on the same day.
• during 1998 electronic links to all GP surgeries.
• by 2002 patients will know the date of hospital appointments when they leave the surgery.
• a Scottish Health Technology Assessment Centre (SHTAC) to provide guidance on the
introduction of new medical technologies including drugs.
•
by 1999 a nurse-led information line providing local information on health and social care
services.
• nationally organised process of quality assurance for clinical services.
“Each of these, when delivered, will improve patient care, patient treatment, and patient
information. I know that Sam Galbraith and I are impatient to see them achieved”.
The White Paper sets out the current context that this project takes place in. This project fits
exactly with the designs of the White Paper and starts from a point of some advancement with
regard to it’s aims. Using the infrastructure already provided by the IT Strategy and linking with the
Integration Project and CHI roll out which has just started it represents an opportunity to quickly
deliver results first in Argyle and Clyde and GGHB and then onto Scotland . The RAH supported by
the HB and local GPs has already tried and tested a number of the technologies required and has
developed a system written by clinicians which meets their needs and could be made available to
the rest of the NHSiS either as an independent system or a more integrated part of GPASS.
10
Statement of Support From GPASS
New GPASS has proved a great success within GP Practices and the NHSiS has a real
opportunity to benefit from a technically advanced, open and robust software product which
provides considerable clinical benefit to its users. This is reflected in the GPASS
Development Strategy (at present in draft awaiting approval). Key to this Strategy is a clear
Vision that GPASS:
• Continues to develop for existing customers
• Develops to support new customers
• Provides information to support clinical governance and needs assessment
• Provides support for clinical decision making
• Drives sharing of information between Clinicians
• Develops to provide the standard clinician ‘desk-top’
• Is reused avoiding expensive ‘reinventing of wheels’
• Continues to develop with technical innovation
The proposed RACHEL Project is clearly aligned with most if not all the elements of the
Vision for GPASS. As such the project can only advance the development of GPASS and
further benefit its stakeholders and the NHSiS in general. Thus GPASS support the proposal
and look forward, with enthusiasm, to its implementation.
Martin Irving
Development Director GPASS
11
Statement of Support from General Practice
Dr Stewart McCormick, Incle Street Surgery, Paisley
I have been a member of the CareNet Steering Committee since its inception. I first became
involved because the technology offered was attempting to solve the problem of the timely
and accurate transmission of discharge information which, like most GPs, I was
experiencing. Often, patients would be admitted to and discharged from the Coronary Care
Unit of the RAH and the first time I learnt of the admission was when the patient presented at
the surgery or I was asked to visit the patient at home.
With the CareNet system, I am now able to receive an electronic discharge summary when
the patient is discharged from the RAH. This accurate and immediate information allows me
to make much more informed decisions on the future care of the patient.
From the application to extend the scope of the project I can see a number of benefits which
will improve the information available to the GP when he or she is considering the care plan of
a patient with coronary heart disease. In particular, the ability to view previous ECGs and
reports of other cardiovascular investigations will allow comparison with present results, which
might change a diagnosis and influence treatment plans. It is also proposed to make the
system two-way, allowing GP information to be added to the CareNet database.
Online booking of outpatient appointments is a function which the Scottish Office expects all
GPs to be able to perform in the near future. The fact that this project aims to deliver this
potential through the present CareNet screen or via GPASS will allow us to test this system
first and to deliver the perceived to our patients.
Before these benefits can be integrated into our day-to-day work practices, however, I believe
that the stability and functionality of the system must be improved. Unless there is a solid,
adequately funded infrastructure with staff dedicated to maintaining and developing the
system, it will be very difficult to keep the momentum going and to roll out the project beyond
the pilot sites. The co-operation with the GPASS development team to integrate CareNet into
GPASS NT will facilitate the roll out of the project outwith the local area and, in combination
with the CDSS, will be a useful addition to the GP consulting room.
12
The functionality of the system requires to be improved and matured before it can be
considered as a solution to the problem of communication between primary and secondary
care. I would like to see:• A dedicated support team responsible for solving ad-hoc problems experienced by GPs
• A group of GPs who report and review problems with the system with the aim of long
term development
• Improvements in the reliability of the system
• Funding sufficient to allow the above to happen
13
Hospital IT Strategy Statement
The Executive of the Argyll and Clyde Acute Hospitals Trust is supportive of the Business
Case that is being submitted to the Scottish Office to extend and develop the present CareNet
project. The Trust has been developing its Information Services infrastructure for many
years, and early connection to NHSnet is an example of its commitment to utilising
information technology to improve communications between health professionals. This project
is in line with this commitment.
The Trust is also committed to increasing the use of telemedicine in general as demonstrated
by our recent purchase of teleradiology and videoconferencing equipment to take part in a
telemedicine network serving Argyll and Clyde Health Board. Trust staff were key players in
instigating this network and are enthusiastic in implementing and developing these systems.
The fact that the project hopes to alleviate many of the communication problems to primary
care, especially with respect to online appointment booking and referrals is an important
benefit the Trust will accrue, and is, in fact, mandated by national strategy.
Whilst a comprehensive IM&T strategy for the new Argyll and Clyde Acute Hospitals Trust
has not yet been developed, the CareNet development is completely aligned with the aims
and objectives of the existing Royal Alexandra Hospital IM&T strategy. It is not therefore
foreseen that the development of the new IM&T strategy will conflict with CareNet in any way.
14
Statement of Support from Argyll & Clyde Health Board
Dr John Jamieson, General Practice I.T. Support Officer
The groundwork for this innovative approach to shared patient care was laid by the NHSiS
Management Executive’s 1997 Primary Care Telecommunications Initiative (PCTI), which
provided each general medical practice with a secure, fast connection to the NHS Network.
However, it was the insight, drive and enthusiasm of the two main groups of collaborators
which were the surest guarantee that this development would be a success. Dr Findlay and
his team saw the benefits to patients of recording and sharing with general practice the wealth
of information about the treatment and care provided within his department. Professor
Goldberg and his colleagues saw the potential of the newly emerging Internet browser
technologies for making the link to general practice.
As the Health Board’s representative on the Project Steering Group, I have been able to
observe the prototyping exercise and have been impressed by the pragmatic approach
adopted and the willingness to consider change demonstrated by all participants. Throughout
the development it was recognised that, although the cardiology specialty was an important
area for development, the principles and the mechanisms could equally be applied to all
aspects of shared patient care.
The clear purpose of this exercise was to investigate the feasibility of the shared care model.
The transfer of the shared cardiology information to the general practice system’s patient
record is due to be explored in collaboration with the developers of the new, Windows-based,
General Administration System for Scotland (New GPASS). The development of a more
robust, more widely applicable and supportable application should now be undertaken.
In my view, the joint development of the CareNet scheme by the Department of Cardiology of
the Royal Alexandra Hospital NHS Trust and the University of Wales Department of
Informatics represents a major step towards the achievement of an important objective of the
1997 white paper Designed to Care and is entirely consistent with the NHSiS’s IT Strategy.
The Health Board recognises the potential for this approach to be applied across the whole
range of hospital specialties to the benefit of patients and welcomes the initiative being taken
by the partners to bid for central funding for the further development of this scheme.
15
4. Background
The Royal Alexandra Hospital NHS Trust faces a problem that affects all hospital trusts. That
is, how to meet the increasing demand for more and speedier communication of clinical
information to General Practitioners, Health Authorities, Professions Allied to Medicine, and
patients themselves. This has resulted in clinicians spending significantly greater time on nonclinical administrative duties. While recognising the importance of this it has diverted precious
clinical resource time which could more properly be spent on direct patient care. An ever
increasing number of inpatient admissions, outpatient consultations, and requests for tests
has also increased the workload for secretarial and administrative staff. This is far from
satisfactory for all concerned. It is now recognised that a situation has arisen where despite
devoting an increase in valuable clinical and clerical time to this problem, that this traditional
approach is straining to cope with these communication problems.
One such problem is the provision of timely and accurate discharge summaries to General
Practitioners. There is no doubt that despite concerted efforts through audit, contracting tools
and such like, that targets for the transmission of these summaries, together with test results
are not being met. It is no wonder that there is a growing dissatisfaction in primary with
secondary care providers around this issue
It was against this background that the Cardiology Department of the Royal Alexandra
Hospital chose to work with the Centre for Health Informatics, at the University of Wales,
Swansea, in order to explore an electronic solution to these problems.
The Cardiology department of the Royal Alexandra Hospital produced discharge summaries
in the time honoured traditional way. That is, summaries were dictated by the consultant staff,
using the medical record as a prompt. These were then typed up by a secretary, validated
and signed by the consultant staff, and posted out in due course to the GP. The time from the
patient leaving hospital to GP receiving this letter was anything up to six weeks after
discharge. It was a time consuming, cumbersome and unsatisfactory method of trying to
share information.
Now however the Coronary Care Unit within the Cardiology department, currently collect
patient information through a Microsoft Access database system, called the CCU system.
This acts as the medium through which information for the CareNet system is also collected,
and is transmitted instantly, on-line via a web based browser to 8 general practices in our
district. This has been developed in house using cardiac research funds.
A forerunner to the development of the CCU system was the adoption of a paper based,
standardised clerking form, used for acute chest pain admissions. From this, came the design
template for the original CCU system. A copy of this form can be found as -Appendix I. - chest
pain admission form.
The process of entering data into the CCU, and by default onto the CareNet system can be
describe as follows:•
The simple tick box acute chest pain admission form is completed by the junior doctor. It
is then passed on to the Named Nurse in the CCU who is then responsible for entering
the information collected thus far into the CCU database. A real time link has been
developed by CSC Health care to support access to the hospital PAS (Compas) Master
Patient Index (MPI). The nurse enters the patient’s hospital number if known, which
triggers the ability to download demographic details from the MPI. Once all the relevant
data has been entered, the system supports the generation of two forms: the Nursing
Admission Form and the Consultant Opinion Form. The nursing form contains the medical
and nursing information that nurses require for their nursing documentation, and is easily
updated as required. A copy of this form can be found as Appendix II. Nursing Admission
Form.
16
•
The Named Nurse prints a Consultant Opinion summary form for the consultant’s ward
round. This contains all the patient’s demographic and admission details allowing space
for the consultant’s opinion to be entered. A copy of this form can be found as Appendix
III. Consultants’ Opinion Form.
•
At this point, new data is entered by hand on the paper record and the computer is
updated following the ward round. There is obvious duplication of paperwork at this point
and is particularly noticeable when comparing medical and nursing notes.
In an attempt to address this problem we have successfully explored the use of a live radio
link from a laptop computer to the central server. The data collection has undergone
progressive change and new forms are under evaluation. The aim is to amalgamate the
medical and nursing notes (Appendix III). An extension of this would be the use of notebook
PC’s for nurses to enter live data as they go about ward duties..
This model has allowed us to examine problems encountered with electronic data collection
and attitudes of staff to this new working practice. It is interesting that junior medical and
nursing staff have accepted this technology with enthusiasm.
17
5. Objectives & Benefit Criteria
Cardiovascular (CVS) disease has been identified by the government as being a priority
disease area, with a commitment to cut the number of patients who present with this disease.
The language used to describe it is shared and understood by all health professionals
involved in managing it. The areas of disease management on which we wish to concentrate
are well defined and can be readily recorded if so desired. Protocols of care are at an
advanced stage and CVS disease has been well audited and lends itself well to evidence
based practice.
The objective of this project is then to enhance the present level of care with a truly
integrated Patient Information System which will support clinicians at all stages of
patient care activity.
The Gartner intelligence report on cardiology systems (appendix iv) indicates that the
necessary elements which will be required for the best cardiology systems are already in
place in the CareNet product. Only the Minerva system comes close in terms of functionality
but lacks the NHSNet capability already tested in this system.
The Benefit Criteria we will use to evaluate the possible options for achieving our objective
are:
Criteria (in descending order of weight)
Weight
1. Improvements in Outcomes
14
2. Clinical Governance
12
3. Electronic GP referral and notification
11
4. Making White Paper time constraints
11
5. Creation of a shared ECPR
10
6. Seamless Care
10
7. Availability of test results/ECGs
8
8. Use of CHI
8
9. Standard Data set and coding
4
10. Use of NHSnet
4
11. Data collection part of normal care
4
12. Use of agreed common drug formulary
4
6. Options
(a) Do Nothing
(b) Develop New System
(c) Build upon CareNet
18
(d) Wait for Integration to be established
A. Do Nothing
The do nothing option would mean RAH keeping the CareNet system in its current state. The
system would not be further developed or enhanced and would simply be maintained to
ensure its continued use in RAH and the currently participating GP practices.
B. Develop New System
RAH could become involved with the Scottish Office in creating a new System to replace
CareNet and fit with the IT Strategy and White Paper. This would bring other Cardiac Care
Units in at the beginning of development work and allow for a clean slate in terms of the
functionality and capability of the system eventually allowing the linking of primary, secondary
and tertiary healthcare centres.
C. Build Upon CareNet
This option allows us to construct an integrated EPR/EHR using the building blocks provided
by the infrastructure investments made by the Scottish Office. This option will deliver the
objectives building upon the work done in the existing Carenet project.
D. Wait For Integration To Be Established
Like the Do Nothing Option RAH would maintain CareNet and wait for the integration of
clinical systems first at Hospital level then through NHSNet and the various gateways. The
CareNet system or a replacement system could then be made compatible with this work.
19
Options Against Benefit Criteria
Benefit Criteria Description
Weight
Opt A
Opt B
Opt C
Opt D
Improvements in outcomes
14
0
126
112
126
Clinical Governance
12
0
120
108
120
Electronic GP referral &
notification
11
0
110
88
110
Making White Paper time
constraints
11
0
55
99
0
Creation of shared ECPR
10
0
100
90
100
Seamless care
10
0
100
90
100
Availability of test results
8
0
80
64
80
use of CHI
8
0
80
80
80
Standard data set & coding
4
0
40
40
40
Use of NHS Net
4
0
32
40
32
Data collection part of normal care
4
0
32
40
32
Use of agreed drug formulary
4
0
40
32
40
Total
100
0
915
883
860
Options Against Benefits Criteria: Descriptions Of Scores
Option A “Do Nothing” will not score against the Benefit Criteria representing the current
service and is therefore ignored in the following explanation.
Improvement in Outcomes (Weight 14%)
a)
No Change (0)
b)
It must be assumed that a specifically designed integrated product will lead to
improved outcomes (9).
c)
The CareNet development will evolve and improve outcomes and can be
monitored and evaluated as it will be working as it is developed (8).
d)
It must be assumed that an integrated product set up under specific
standards will lead to improved outcomes (9).
The development of clinical governance through the best practice (Weight 12%)
a)
No Change (0)
20
b)
It must be assumed that an integrated product that has been designed by a
multidisciplinary multi-site representative team should allow for the
development of clinical goverence (10).
c)
The CareNet development will if successful evolve a wider group that will
allow for the development of clinical governance (9).
d)
It must be assumed that an integrated product set up under specific
standards will lead to clinical goverence (10).
Electronic GP referral and notification (Weight 11%)
a)
No Change (0)
b)
It must be assumed that an integrated product will provide this (10).
c)
The CareNet system will develop this (8).
d)
It must be assumed that an integrated product set up under specific
standards will have this (10).
Making White Paper Time Constraints (Weight 11%)
a)
No Change (0)
b)
A new product would require a heavy investment in time and money to make
the required timescales (5).
c)
The CareNet system is already available with a number of the features
required and could be developed in line with the White Paper timescales (9).
d)
It must be assumed that an integrated product set up under specific
standards will not meet the timescales (0).
21
The creation of a shared ECPR (Weight 10%)
a)
No Change (0)
b)
It must be assumed that a specifically designed integrated product will
provide an ECPR (10).
c)
The CareNet development will evolve and create an ECPR as it is developed
(9).
d)
It must be assumed that an integrated product set up under specific
standards will lead to an ECPR (10).
Seamless Care (Weight 10%)
a)
No Change (0)
b)
It must be assumed that an integrated product will provide this (10).
c)
The CareNet development will in particular target the information required to
allow this (9).
d)
It must be assumed that an integrated product set up under specific
standards will lead to this (10).
The availability of test results including ECGs (Weight 8%)
a)
No Change (0)
b)
It must be assumed that an integrated product will contain this (10).
c)
The CareNet development will as part of it’s first two phases, test the
technology for this and in particular develop work already started (8).
d)
It must be assumed that an integrated product set up under specific
standards will lead to this (10).
22
Use of the CHI (Weight 8%)
a)
No Change (0)
b)
A new product would require to use CHI (10).
c)
The CareNet system will be developed in line with the HBs policies for use of
CHI (10).
d)
It must be assumed that an integrated product set up under specific
standards will lead to this (10).
Standard Data set and coding (Weight 4%)
a)
No Change (0)
b)
It must be assumed that an integrated product will provide this (10).
c)
The CareNet development will as part of it’s first phase achieve this (10).
d)
It must be assumed that an integrated product set up under specific
standards will lead to this (10).
Use of NHSNet (Weight 4%)
a)
No Change (0)
b)
It cannot be be assumed that an integrated product will automatically be
capable of using the existing NHSNet and PCs currently available but this
could be a constraint put on the project (8).
c)
The CareNet system will continue to use the current infrastructure (10).
d)
It cannot be assumed that an integrated product set up under specific
standards will lead to this (8).
23
Data collection as part of the normal care routine (Weight 4%)
a)
No Change (0)
b)
It cannot be be assumed that an integrated product will automatically be
capable of fitting with current clinical protocols although this could be a
constraint put on the project (8).
c)
The CareNet system will continue to develop based on established and
currently used protocols (10).
d)
It cannot be assumed that an integrated product set up under specific
standards will lead to this (8).
Use of agreed common drug formulary (Weight 4%)
a)
No Change (0)
b)
A new product would be required to have this (10).
c)
The CareNet system is being developed possibly with GPASS to contain this.
(8)
d)
It must be assumed that an integrated product set up under specific
standards will contain this (10).
24
7. Costs
Option A
Do Nothing
No new costs under this option
25
Optbion B
Develop New System
000s
Hardware
Capital/
Revenue
Year
1
Year
2
Year
3
000s
000s
000s
PCs
C
30
15
15
Laptops
C
10
5
5
Servers
C
20
Printers
C
10
Databases
C
5
Operating Systems
C
2
Software
Support
Grade
Project Manager
R
B13
21.7
22.6
23.5
Consultant Cardiologist 1
R
CON
10
10
10
Consultant Cardiologist 1
R
CON
5
5
5
IT Support Staff
R
A&C 5
16
16
16
IT Support Staff
R
A&C 5
16
16
16
Database developer 1
R
A&C 6
17.1
17.6
18.1
Database developer 1
R
A&C 6
17.1
17.6
18.1
DatabaseSupervisor
R
CON
25
25
25
Junior Doctor IT specialist
R
SHO3
5
5
5
Nursing Liason
R
G
23
23
23
Project Administration 1
R
A&C 4
7
7
7
Project Administration 1
R
A&C 4
7
7
7
Project Board
R
20
20
20
Evaluation group
R
5
5
5
26
GPs
R
20
20
20
Centre for Health Infomatics
(inc expenses)
R
47
47
47
TOTAL / per annum
261.9 263.8 271.7
Overheads
C
33.4
33.6
33.9
Consumables
C
25.7
25.9
26.1
GRAND TOTAL
321.0 323.3 325.7
Training
PRinCE2
C
2
NHSnet upgrade
C
30
Topas Link (outpatients)
C
25
Other costs
TOTALS
Capital
134
20
20
Revenue
305
307
310
TOTAL P.A.
439
327
330
TOTAL COST OF PROJECT
1,095,972
27
Option C
Develop Existing System
Hardware
Capital/
Revenue
Year 1
Year 2
Year 3
000s
000s
000s
PCs
C
20
10
10
Laptops
C
5
5
5
Servers
C
10
Printers
C
5
Databases
C
2
Operating Systems
C
1
Software
Support
Grade
Project Manager
R
B13
11
22.6
23.5
Consultant Cardiologist
R
CON
10
10
10
IT Support Staff
R
A&C 5
15.8
16.4
17
Database developer
R
A&C 6
17.1
17.6
18.1
DatabaseSupervisor
R
CON
25
25
25
Junior Doctor IT Specialist
R
SHO3
5
5
5
Nursing Liason
R
G
23
23
23
Project Administration
R
A&C 4
7
7
7
Project Board
R
10
10
10
Evaluation group
R
5
5
5
GPs
R
10
10
10
Centre for Health Infomatics (inc
expenses)
R
47
47
47
185.9
198.6
200.6
TOTAL / per annum
28
Overheads (at 13%)
C
23.5
25.2
25.4
Consumables (at 10%)
C
18.1
19.4
19.6
227.5
243.1
245.6
Year 1
Year 2
Year 3
Capital
85
15
15
Revenue
228
243
246
TOTAL P.A.
313
258
261
GRAND TOTAL
Training
PRinCE2
C
2
NHSnet upgrade
C
15
Topas link (Outpatients)
C
25
Other costs
TOTALS
TOTAL COST OF PROJECT
£ 831,223
29
Option D
Wait For Integration To Be Established
Hardware
Capital/
Revenue
Year 1
Year 2
Year 3
000s
000s
000s
PCs
C
20
10
10
Laptops
C
5
5
5
Servers
C
10
Printers
C
5
Databases
C
2
Operating Systems
C
1
Software
Support
Grade
Project Manager
R
B13
11
22.6
23.5
Consultant Cardiologist
R
CON
10
10
10
IT Support Staff
R
A&C 5
15.8
16.4
17
Database developer
R
A&C 6
17.1
17.6
18.1
DatabaseSupervisor
R
CON
25
25
25
Junior Doctor IT specialistb
R
SHO3
5
5
5
Nursing Liason
R
G
23
23
23
Project Administration
R
A&C 4
7
7
7
Project Board
R
10
10
10
Evaluation group
R
5
5
5
GPs
R
10
10
10
138.9
151.6
153.6
TOTAL / per annum
30
Overheads (at 13%)
C
23.5
25.2
25.4
Consumables (at 10%)
C
18.1
19.4
19.6
180.5
196.1
198.6
Year 1
Year 2
Year 3
Capital
85
15
15
Revenue
181
196
199
TOTAL P.A.
266
211
214
GRAND TOTAL
Training
PRinCE2
C
2
NHSnet upgrade
C
15
Topas Link (Outpatients)
C
25
Other costs
TOTALS
TOTAL COST OF PROJECT
£ 691,223
These cost estimates are based on all work and support being provided from within the Health Service. The
current Integration project may provide facilities which can be called upon and therefore replace some of
the elements for which charges have been allocated.
The cost of developing a new system with the required integration and communication has been based on
all work and support being provided from within the Health Service. It would be possible to procure a
software house to carry out the same task but given the need for clinical involvement we feel that this
would increase the cost.
The cost of each option covers the required capital and revenue implications to develop the project and
make the system available within RAH, it does not cover the costs that would be accrued by other
Secondary Health facilities if they were to adopt the system. Primary Health facilities should not have
additional costs as the system will be designed to work through the GP gateway.
31
Discount Analysis
Option A
99/00
00/01
01/02
Year 0
Year 1
Year 2
Capital
£0.00
£0.00
£0.00
Revenue
£0.00
£0.00
£0.00
Total
£0.00
£0.00
£0.00
Discount
Factor
1.0000
0.9434
0.8900
Present Value
£0.00
£0.00
£0.00
Do Nothing
Net Cash Flow
£0.00
Sum of Present Values = NPV Costs
£0.00
Annulizing Factor for Years 0 to 2 at 6% 1+1.8334
Equivalent Annual Cost
£0.00
32
Option B
99/00
00/01
01/02
Year 0
Year 1
Year 2
Capital
£134000.00
£20000.00
£20000.00
Revenue
£305000.00
£307000.00
£310000.00
Total
£439000.00
£327000.00
£330000.00
Discount
Factor
1.0000
0.9434
0.8900
Present Value
£439000.00
£308490.57
£293698.83
Develop New
System
Net Cash Flow
£1096000.00
Sum of Present Values = NPV Costs
£1041189.39
Annulizing Factor for Years 0 to 2 at 6% 1+1.8334
Equivalent Annual Cost
£367470.91
33
Option C
99/00
00/01
01/02
Year 0
Year 1
Year 2
Capital
£85000.00
£15000.00
£15000.00
Revenue
£228000.00
£243000.00
£246000.00
Total
£313000.00
£258000.00
£261000.00
Discount
Factor
1.0000
0.9434
0.8900
Present Value
£313000.00
£243396.23
£232289.07
Build upon
Carenet
Net Cash Flow
£832000.00
Sum of Present Values = NPV Costs
£788685.30
Annulizing Factor for Years 0 to 2 at 6% 1+1.8334
Equivalent Annual Cost
£278353.69
34
Option D
01/02
02/03
03/04
Year 0
Year 1
Year 2
Capital
£85000.00
£15000.00
£15000.00
Revenue
£181000.00
£196000.00
£199000.00
Total
£266000.00
£211000.00
£214000.00
Discount
Factor
1.0000
0.9434
0.8900
Present Value
£266000.00
£199056.60
£190459.24
Wait for
Integration
Net Cash Flow
£691000.00
Sum of Present Values = NPV Costs
£655515.84
Annulizing Factor for Years 0 to 2 at 6% 1+1.8334
Equivalent Annual Cost
£231353.69
35
6. Risk Analysis
A comparison of risks against options has been done and is summarised below. The costings
are used to weight the risks against each other to allow the comparison to look at risk against
risk.
Risk Description
Opt A
Opt B
Opt C
Opt D
Non-acceptance by other cardiology centres
0.00
3000.00
15000.00
3000.00
Non-fit with hospital IT strategy
0.00
10000.00
10000.00
0.00
Technically not possible
0.00
3000.00
3000.00
0.00
lack of resilience
0.00
500.00
5000.00
500.00
NHSNet Delays
0.00
5000.00
5000.00
5000.00
Failure to Convince users locally
0.00
10000.00
20000.00
20000.00
Cost estimates too low
0.00
10000.00
10000.00
10000.00
lack of agreement on gateway
0.00
10000.00
10000.00
1000.00
Patient Information security
0.00
2500.00
2500.00
2500.00
300000.00
150000.00
30000.00
210000.00
0.00
5000.00
0.00
10000.00
300000
209000
110500
262000
Failure to achieve White Paper Targets
Lack of Cardiologist's time
Total
Risk Description
1. Non acceptance by other Cardiology Centres. With any system which will be required to
be used by a wide group of professionals their is a risk of systems being viewed as an
attempt to change work practices or interfere with clinical freedom. A cost for weighting
purposes has been put against this of the approximate cost of developing a clinical system
£300,000. (Based on previous cost of developing a cardiology system some years ago)
2. Non-fit with Hospital IT strategy. There is a risk that the work on the system does not coordinate well with the direction the Trust takes in it’s IT strategy. The cost for weighting
£200,000 represents a cost for adding cardiology functionality to another integrated
solution the Trust may move to. (Cost based on recent quotes in Aberdeen for clinical
modules)
3. Technically not possible. That the solution is not technically possible. The cost for
weighting £300,000 is the possible cost for having to design a different system in place of
the chosen method. (Based on previous cost of developing a cardiology system some
years ago
4. Lack of resilience. The cost for weighting is £50,000 based on IT development costs to
convert systems from one platfrom to another.
36
5. NHSNet delays. A weighting cost of £100,000 is a nominal figure for weighting based on
project delays this may cause.
6. Failure to convince Users locally. This reflects the risk of local Users not being behind the
project. A weighting figure of £200,000 has been used to reflect the risk of wasted money
before this becomes apparent.
7. Cost estimates too low. This risk reflects the possibility that the option has been priced too
low and would require additional funding to achieve results (£100,000).
8. Lack of Agreement on gateway. Delays in agreeing the gateway format may delay the
project and increase costs. (100,000)
9. Patient Information security. This reflects the risk that delays are experienced due to
problems in either ensuring security of information or convincing organisations that the
system meets their security requirements. (50,000)
10. Failure to achieve white paper targets. A weighting cost of £300,000 is being used to
measure additional costs and resources that would avoid delays in meeting White paper
targets.
11. Lack of Cardiologists time. For comparative purposes this has been weighted at £50,000
representing additional locum cover.
37
Risk Description - Opt A
Cost
% Chance
Total (Cost × Chance)
Non-acceptance by other cardiology centres
300000.00
00%
0.00
Non-fit with hospital IT strategy
200000.00
00%
0.00
Technically not possible
300000.00
00%
0.00
lack of resilience
50000.00
00%
0.00
NHSNet Delays
100000.00
00%
0.00
Failure to Convince users locally
200000.00
00%
0.00
Cost estimates too low
100000.00
00%
0.00
lack of agreement on gateway
100000.00
00%
0.00
Patient Information security
50000.00
00%
0.00
Failure to achieve White Paper Targets
300000.00
100%
300000.00
Lack of Cardiologist's time
50000.00
00%
0.00
Total
300000
Option A which achieves none of the benefits therefore scores 0 in all risks except failure to achieve white paper
targets in which it will score 100%. cover.
38
Risk Description - Opt B
Cost
% Chance
Total (Cost × Chance)
Non-acceptance by other cardiology centres
300000.00
01%
3000.00
Non-fit with hospital IT strategy
200000.00
05%
10000.00
Technically not possible
300000.00
01%
3000.00
lack of resilience
50000.00
01%
500.00
NHSNet Delays
100000.00
05%
5000.00
Failure to Convince users locally
200000.00
05%
10000.00
Cost estimates too low
100000.00
10%
10000.00
lack of agreement on gateway
100000.00
10%
10000.00
Patient Information security
50000.00
05%
2500.00
Failure to achieve White Paper Targets
300000.00
50%
150000.00
Lack of Cardiologist's time
50000.00
10%
5000.00
Total
209000
Option B Designing a new system from scratch scores high in benefits but also scores high in the risk of failing to
achieve white paper timescales. It has medium risk in the areas of lack of cardiologists time, cost estimates too low
and lack of agreement on the gateway.
39
Risk Description - Opt C
Cost
% Chance
Total (Cost × Chance)
Non-acceptance by other cardiology centres
300000.00
5%
15000.00
Non-fit with hospital IT strategy
200000.00
5%
10000.00
Technically not possible
300000.00
1%
3000.00
lack of resilience
50000.00
10%
5000.00
NHSNet Delays
100000.00
5%
5000.00
Failure to Convince users locally
200000.00
10%
20000.00
Cost estimates too low
100000.00
10%
10000.00
lack of agreement on gateway
100000.00
10%
10000.00
Patient Information security
50000.00
5%
2500.00
Failure to achieve White Paper Targets
300000.00
10%
30000.00
Lack of Cardiologist's time
50000.00
0%
0.00
Total
110500
Option C Build upon the existing system scores high in benefits but higher than the rest in the risk of failing to
achieve a resilient system. It is low in terms of failure to achieve the white paper timescales. It also has medium risk
in the areas of cardiologists time, cost estimates too low and lack of agreement on the gateway.
40
Risk Description - Opt D
Cost
% Chance
Total (Cost × Chance)
Non-acceptance by other cardiology centres
300000.00
01%
3000.00
Non-fit with hospital IT strategy
200000.00
00%
0.00
Technically not possible
300000.00
00%
0.00
lack of resilience
50000.00
01%
500.00
NHSNet Delays
100000.00
05%
5000.00
Failure to Convince users locally
200000.00
10%
20000.00
Cost estimates too low
100000.00
10%
10000.00
lack of agreement on gateway
100000.00
01%
1000.00
Patient Information security
50000.00
05%
2500.00
Failure to achieve White Paper Targets
300000.00
70%
210000.00
Lack of Cardiologist's time
50000.00
20%
10000.00
Total
262000
Option D which scores high in benefits scores high in the risk of failing to achieve white paper timescales. It also has
medium risk in the areas of cardiologists time, cost estimates too low and lack of agreement on the gateway and
failure to convince local Users.
In comparison Option C building upon the work already started appears to have least risk when considered.
In particular the risk of not making the white paper targets would be least in this option.
41
7. Preferred Option
The preferred option is C building on the existing project.
Option
Total Cost
NPV
Benefit Score
Risk Score
A
£0.00
£0.00
0
300,000
Do nothing
B
Highest Risk
£1,096,000
£1,041,189
915
rd
3 Highest
Risk
Develop New
System
C
£832,000
£788,685
883
Develop Present
Systems
D
209,000
110,500
Lowest risk
£691,000
Wait for Integration
and develop CCU
System
£655,515
860
262,000
nd
2 highest
Risk
A. Do Nothing
The do nothing option would mean RAH keeping the CareNet system in its current state. The
system would not be further developed or enhanced and would simply be maintained to
ensure its continued use in RAH and the currently participating GP practices. This option
scores 0 against benefit criteria and has no possibility of making white paper targets. It
represents no improvements in patient care and can therefore be dismissed.
B. Develop New System
RAH could become involved with the Scottish Office in creating a new CCU System to
replace CareNet and fit with the IT Strategy and White Paper. This would bring other Cardiac
Care Units in at the beginning of development work and allow for a clean slate in terms of the
functionality and capability of the system eventually allowing the linking of primary, secondary
and tertiary healthcare centres. The disadvantage of developing a new system is that there is
no general EPR/EHR system emerging at present and in a sense this could be regarded as a
wait and see option as far as the NHSnet is concerned There are major risks in trying to
establish an EPR across such a wide range of players. A national strategy would inevitably
lead to delays in development by which time much momentum and enthusiasm would be lost.
It is felt that no improvement in patient care will result from this in the short term. Although
scoring marginally higher in potential benefits, it would be unlikely to meet White Paper
targets and represents the highest cost.
This Option is not recommended
42
C. Build Upon CareNet
This option allows us to construct an integrated EPR/EHR using the building blocks provided
by the infrastructure investments made by the Scottish Office. CareNet fits in with the Scottish
IT strategy not necessarily at the detailed cardiology application level (i.e it does not represent
an all-Scotland agreement on what a national cardiology system should contain) but it does
embrace all the generic elements of the strategy. The opportunity CareNet presents is an
nd
exemplification of the Scottish Strategy. This scores 2 highest in terms of benefits and
lowest in terms of risk . It is the second highest cost. There are benefits to be gained by
developing a system around a cardiology application which demonstrates all the clinical
opportunities to be gained from the wholehearted embracing of health informatics or
telemedicine applications.
We feel this project should be regarded as a generic testbed for a range of uses for electronic
records in supporting healthcare delivery. Although CareNet draws on the RAH CCU system
for the bulk (at present) of its data the application is generic in as much that it could derive
data from a wide range of clinical sources and this is being exemplified through the cardiology
application. MUSEWEB is such an application which is best delivered through CareNet to
avoid a multiplicity of different systems being presented to it.
It is entirely possible that the rest of the NHSiS could take and use the CareNet system as a
starting point, after a period of technology testing and development together with evaluation of
success undertaken with the Scottish Office. If successful and a Multidisciplinary Multi-Health
Board team could be set up to roll out the CareNet system or the standards developed for
other systems into a NHSiS wide program of linking the specialist centres at primary,
secondary and tertiary levels. But it is more likely that others would want to take the
experience and the lessons learnt from the development. This would leave cardiology
departments free to develop their own clinical systems while benefiting from all the
infrastructure investments and lessons learnt within this project. This is the preferred option
giving the best improvements in patient care in line with the white paper and in the shortest
timescale.
This Option is recommended
D. Wait For Integration To Be Established
Like the Do Nothing Option RAH would maintain CareNet and wait for the integration of
clinical systems first at Hospital level then through NHSNet and the various gateways. The
CareNet system or a replacement system could then be made compatible with this work. This
is effectively the same as option A and RAH would be bound to use the integration services
once they become available. This option will not deliver short term improvements in patient
care and basically misses the opportunity to exploit the availability of work already undertaken
and more critically the enthusiasm of the RAH team. It will not meet the White Paper targets.
It is higher in risk than Option C and although it appears lowest in cost it does not include the
additional costs to the NHSiS in developing the technologies that option C will deliver.
This option is not recommended.
43
The Preferred Option
Option C represents therefore the best way to achieve improved patient care in the shortest
timescale using the existing infrastructure.
Please see the attached report (appendix VIII) from Dr A F Rickards, FRCP, FACC. FESC,
Consultant Cardiologist.
The costs however when compared demonstrate that developing a set of standards and the
required technology from scratch (Option A) would prove to be the most expensive. Option D
would not include the development work which would have to be undertaken in other projects.
Option C demonstrates an affordable option that would develop the required technology and
deliver a solution in an acceptable timescale.
The preferred option in detail.
Phase 1:
build upon the existing system and test the technology in new areas:
Further work will be undertaken to incorporate clinical governance guidelines and protocols
into the system. In many ways this is the most important clinical part of this project. Clinical
governance is new to us all but should ensure the following:
the delivery of high quality care
(a) implementation of clinical guidelines
(b) critical event analysis
(c) clinical effectiveness
We propose to deliver high quality care of patients presenting with acute coronary syndromes.
We will enhance the diagnostic accuracy of junior doctors in A+E by
•
cardiology image transfer
•
employment of intelligent decision supports systems
Cardiology Image Transfer:
We will achieve the electronic transmission of ECGs outside normal working hours from A+E
to a consultant cardiologist for a definitive opinion in cases of diagnostic uncertainty.
At the present time, all cardiology test results at the RAH, are held on a first generation
Marquette MUSE system. The RAH is one of the few hospitals in Scotland to have computer
storage of all ECG, Exercise test, and 24-Hour Holter ECG analysis. We have installed the
new Marquette MUSEWEB system. (http:/museweb1.mei.com, user name – webuser1,
password webuser1). This allows us to transmit an ECG in two ways.
1. Direct Fax
The simplest way is direct fax to a mobile communicator (Nokia 9110). We have
demonstrated that this is possible.
44
2. Web browser
The second method involves the electronic evaluation of the ECG image by browsing the
ECG stored on the MUSEWEB from a remote PC. This facility should allow other hospitals to
review ECGs stored at the RAH.
True integration of the CareNet and MUSE systems using the Marquette Web browser will be
achieved in phase 1 of the project. It has been agreed that the RAH becomes a Marquette
luminary site for MUSEWB in Europe, with the emphasis on the unique nature of the NHS
networking capability.
The effect of this ready availability of ECGs will be to increase diagnostic accuracy of acute
myocardial infarction and ensure proper treatment, which can reduce mortality by up to 50%.
Likewise it can reduce the number of patients who receive thrombolytic therapy
inappropriately (which exposes the patient to a 1 in 100 risk of haemorrhagic stroke) because
of misinterpretation of the ECG.
Intelligent decision supports systems
In the pilot phase (see summary) we have installed in A+E a computer linked to the hospital
network/CARENET. Data collected on the admission chest pain form will be entered
electronically. This live data entry taken with the enhanced ECG diagnostic accuracy will be
evaluated with a clinical decision support system developed by Professor Lee Kennedy.
This neural network software was developed as part of a Scottish Office funded project. It
requires clinical evaluation. We expect that this will enable junior doctors to give a more
accurate diagnosis when assessing patients with acute chest pain syndromes and will
achieve our objectives with regard to clinical governance guidelines as stated above. We
further anticipate that this will lead to improved clinical effectiveness.
We have piloted the use of an acute chest pain admission unit which has led to reduced
length of stay, but the approach taken was an all-encompassing one to patients with chest
pain and we were unable to cope with the large number of admissions. We feel that the
incorporation of above elements will lead to more appropriate admission to the acute chest
pain unit and thus permit more appropriate care and use of resources. (see attached abstract)
Establish a clinical review mechanism to monitor the project
An appropriate non RAH clinical group should be appointed to monitor the project and take a
wider view of it’s progress. The Project Group should report every three months to the Clinical
Review Group.
Development and integration with GPASS of the current CCU database/ Carenet
system.
GPASS will be the clinical database used by the majority of GPs in NHSiS. The development
of a cardiology EPR would be facilitated by seamless transfer of data between our hospital
systems and GPASS. We are exploring such a link between GPASS and CARENET. There is
a strong commitment to this integration of primary and secondary care information systems by
the cardiologists at the RAH.
At present the RAH CCU discharge summary is shown in the context of the hospital
admission. Additional admissions and discharges are shown as being part of a new episode
of care. Once out-patient booking and results reporting are added they will be within the
context of that episode of a patient's care. As information obtained from other hospitals is
added into the enhanced CareNet system resulting from this project this too will be viewed in
the context of an extended but totally shared health record with primary health care.
As an example, as the other parts of a patient's cardiology healthcare experience are added
(such as ECG investigations) they are held within this shared patient record. The GP (under
45
current arrangements) should always view patient information within the context of a single
unified record. This will avoid the need to launch different applications to view different
portions of the patient record (for example, MuseWeb will be accessed via CareNet). Thus
the MuseWeb interface will need to be integrated into the new system so that the GP and
other users will view these results within a unified record.
Once the GP Gateway product is installed, the new system will use it to ensure data is
passed directly into the GP system and it will also interface to the CHI gateway to ensure
universal use of unique patient identifiers.
The further development and evaluation of a common electronic clinical and nursing
record in co-operation with other cardiac centres.
It is likely that other cardiac centres would want to modify any hospital-based database
system for their own purpose. This will apply equally to medical and nursing staff. However, it
is imperative that there is a minimum common dataset of useful clinical information that will be
required by all centres. In this part of the project we will look at other database systems (such
as Minerva) and ensure that similar data definitions are used.
Links to tertiary care
We see the solution we are developing as one that can be transported to other cardiology
departments.
As well as providing a model of how to communicate more effectively between primary and
secondary care, it also addresses the problem of information exchange to tertiary care. Our
main tertiary referral centre is the Western Infirmary, Glasgow (WIG). This centre could
realise the most immediate benefit of the development of project RACHEL. Results of
Percutaneous trasluminal coronary angioplasty (PTCA) and Coronary Artery Bypass Grafting
(CABG) could be transmitted electronically between specialists at WIG and RAH immediately.
An improved system to automate referral and data transfer for cardiac surgery and coronary
angiography would also be possible within the remit of the project. We envision seamless
information sharing through all three levels of healthcare. Results from cardiac surgery and
investigations can be made available to both secondary and primary care by transfer to our
system with a resulting immediate impact on the information available for decision making.
The evaluation of the immediate discharge summaries currently transmitted to GPs
and the further development of the standard discharge letter under the SIGNET
initiative.
At present, as stated above, the GP sees on his screen the data relating to his patients in the
context of the patient’s admission. We propose to develop an electronic discharge letter that
conforms to the SIGNET initiative. Once again this will contain the core dataset but we will
modify the letter to include local protocols (such as prescription of cholesterol lowering drugs,
ACEI therapy, pre-discharge exercise test data). Further information about SINGET can be
found at http://www.rcgp-signet.co.uk/.
The testing and improvement of the resilience of the System
The effectiveness of this system depends on all of its various elements, including:
•
Accurate and complete data entry in A & E
46
•
Accurate and complete data entry in Acute Chest Pain Unit
•
Accurate triggering of electronic data transfer via Carenet
•
Completeness and accuracy of data presented to GPs
•
Ensure data always goes to correct GP
•
Technical robustness of hospital data collection
•
Technical robustness of external NHS-Net based data transmission
The pilot running of the enhanced version of the CareNet system in another Hospital.
Inverclyde Royal Infirmary is one of the hospitals in the new Argyll and Clyde Acute Hospital
Trust. We propose that this hospital be a sister site for this project. This will have the
advantage of being part of the same IT strategy as the RAH.
Develop link to hospital order comms systems labs, pharmacy etc
Laboratories
A link has already been established between haematology and the Coronary Care system,
using the TALK server integration system. However, it is less than ideal: it is too slow and is
not real time. At present, the facility to print biochemistry laboratory reports is available, but
not to access this data electronically.
We propose to develop an EDIFACT-compliant interface between the RAH laboratory system
and the new system. This interface will be based on the Burns software, which is being
supplied to all GP practices participating in the Scottish Office IT Roll-Out Programme. It is
understood that this (GP) software may require further enhancement to support the transfer of
laboratory results. The link to the new system will ensure that all GP practices and CCU will
be able to access laboratory test results.
Pharmacy Links
At present, discharge prescriptions are sent to the pharmacy department and medication
returned to the ward using the internal mail system. It is often the case that due to pressure
on beds, patients are allowed home, returning later for their medication. An electronic link
between the pharmacy department and the Coronary Care Unit would speed up this process.
This will be the pilot for electronic prescribing of discharge medication within the hospital.
The aims of the pilot were:
To assess the feasibility use of electronic prescribing within hospital.
Speed up the delivery of prescriptions from CCU and Ward 8 to pharmacy.
Encourage accurate and secure prescribing of medication, with information that is legible and
comprehensive.
Decrease the number of telephone enquiries to the wards in relation to a patient's
prescription.
47
What has been achieved so far
Development of Electronic Link to Hospital Pharmacy
A computer was installed in the pharmacy department with a connection to CareNet via an
Internet browser and appropriate password-controlled security. When a patient is ready for
discharge, the medical staff verify the electronic Drug Kardex within the Coronary Care
Database, which should be up-to-date following prior entry of data on the ward round laptop.
Once the discharge medication has been finalised, the user is prompted for their username
and password to ensure secure prescribing before the prescription is made electronically
available to the pharmacy department. The prescription is viewed by the clinical pharmacist
on the CareNet system, and is then either confirmed and prepared within the department, or
declined with appropriate reasons that can be viewed in the Coronary Care Database.
This pilot system hopes to encourage accurate, security conscious prescribing of discharge
medication with information that is legible and comprehensive, decrease the number of
telephone enquires to the ward, and speed up the delivery of prescriptions from CCU/Ward 8
to pharmacy. Consequently, the system should also decrease the amount of time that a
patient is required to wait for their discharge medication. If the pilot is successful, we propose
to expand the system to our acute medical receiving ward.
Linking to an electronic drug formulary
Linkage of the electronic prescribing system to an electronic forumarly, such as the electronic
B.N.F., confers the advantages of on-line access to correct prescribing information and
automatic alerts for drug interactions and contraindications. We will seek to link our electronic
prescribing system eithe with e-BNF or with the formulary already incorporated within
GPASS.
Investigation of how ECGs can be digitised from other Hospital’s equipment.
The following hospitals use Marquette MUSE to store their ECGs:
•
Hairmyres
•
Southern GeneraL
•
Crosshouse
•
Raigmore
•
HCI Clydebank.
These hospitals will be able to browse the Web Based Marquette MUSE system at the RAH
given the appropriate authorisation. ECGs stored in the RAH can be viewed on PC,
transmitted to their MUSE or printed on paper. ECGs from their system can be transmitted by
Modem to the RAH and stored on MUSEWEB
The creation of a link with CHI through the HBs chosen method currently being
explored in a separate project
Roll out of system to all GPs in HB.
48
The development of a diabetes version of the system to test the commonality between
the two specialities.
Phase 2
The second phase will set up a multidisciplinary and NHSiS wide team to work on the
evidence of phase 1 and to:
1. Develop the system to work through the GP Gateway to GPASS
2. Establish a method of allowing GPs to refer suitable patients for Hospital
out-patient appointments electronically
3. Establish a standard method of transferring cardiology images from the
hospital to GPs and between hospitals electronically
4. Establish the means to encode data within discharge summaries and to
explore methods of mapping between different coding systems (i.e. ICD10
to Read and vice versa)
5. Create an application which can be rolled out to other CCUs
6. Establish a standard that other CCU systems must meet in order to
become part of the integrated system
7. Establish a support mechanism for the CCU System from an outside or
inside source depending on likely take up of system.
Phase 3
The third phase will:
1. Establish a program of linking other cardiology depts either with their own
systems or CareNet Cardiology to the standard GP Gateway/Hospital
Gateway Cardiology interface
2. Deliver training to GPs and other medical staff on the standard Gateways
3. Instigate a system which will where clinically appropriate allow GPs to refer
patients to hospital for out-patient appointments electronically
4. Provide a support mechanism for the CCU system
5. Establish an on-line database of most recent patient ECGs available to
clinical staff at primary, secondary and tertiary healthcare centres.
49
8. Risk Avoidance Strategy
The aim of the RACHEL project is the establishment of a common electronic
record for primary, secondary and tertiary cardiology care. In establishing this
a whole range of benefits can be achieved. The risks which have already
been identified in section 6 must be minimised to ensure that in the required
timescales it is possible to achieve our goals.
The risk of non-acceptance of the technology by other cardiac centres,
disagreement on the gateway dataset or failure of the system to be accepted
locally will be reduced by four initiatives.
1. The development of a national group to control the system development at the beginning
of phase two (when a system using the technologies will be available but before the data
set is written in stone).
2. The use of cardiologists in the design of the system reducing the risk of the systems
dictating the practice.
3. The approach being adopted to create the data-set/interface that will allow other cardiac
centres to use their preferred systems.
4. The widening of the project group at the Royal Alexandra to cover those departments
which will now become more involved. In particular Labs and Pharmacy which have
indicated their willingness to develop the required communications.
The risk that this project will not fit with the Hospital strategy has already been examined in
strategic context and both the Health Board and Trust confirm that this project is in line with
their goals.
The risk that the project will clash with work being undertaken in other cardiac centres is
minimal. Other cardiac centres have been looking specifically at the transfer of patient images
and telemedicine for examination purposes. This project does not undertake this specifically
but does provide a useful administration system which can be used in conjunction with this
technology giving remote access to records of previous attendance.
Lack of resilience has proved to be a problem in the past but this project concentrates on
setting up a comprehensive support regime for the system and looks to the future to establish
if required a formal mechanism for support in other Trusts.
The risk of cost estimates being too low is a problem with all projects, however a large part of
the work has already been achieved slowly at low cost. The project costs have covered the
required resources and strong project management which has already been demonstrated
will turn these resources into results.
The risk of failing to meet the White Paper Targets has been a factor in choosing this
approach of developing the existing Carenet system. This option represents the only option
that could possibly make the targets. To ensure this happens the project plan will have clearly
stated timescales and milestones that must be achieved.
50
51
1. Appendix I-III : Forms from system
52
Appendix IV: Gartner Market Intelligence Report
53
Appendix V: List of cardiology depts
54
Appendix VI: List of local GPs already connected
connected
55
Appendix VII: Newspaper/ hospital doctor articles etc
56
Appendix VII : Report of a visit to the Royal Alexandra
Hospital (Paisley) to assess the Coronary Care
Carenet Project
Dr A F Rickards, FRCP, FACC. FESC
Consultant Cardiologist*
Royal Brompton Hospital
London SW3 6NP
Email: a.rickards@heart.org.uk
*ex Director of Information, Royal Brompton Hospital
*ex Chairman, British Cardiac Society IT committee
Introduction
The cardiac department at the Royal Alexandra Hospital (RAH) has developed an electronic
patient record accessible both within and without the RAH. They have now made an
application to the Scottish Office to further develop this ‘telemedicine’ project. I was asked to
provide an evaluation of the current project and the future plans both from the (cardiac)
clinical and from a limited technical point of view. This report is based on documents supplied
th
to me by RAH and from a half day visit to the hospital on Friday March 12 1999 when
interviews were conducted with key internal staff and a local GP. My thanks are due to those
interviewed who made the visit both enjoyable and informative (appendix A)
Background
The cardiac team at the RAH were first stimulated to develop an electronic patient record by
the requirements of clinical audit. Specifically it was appreciated that for both internal and
external performance evaluation, clinical data on patients presenting to the unit (dealing
largely with acute coronary disease) had to be collected and evaluated. A coronary care
database storing the essential medical information was developed (in MS Access) and
provides the essential management and performance audit information for the unit.
In designing and implementing the coronary care system the RAH team realised that to
capture the relevant information they had to make the system emulate existing medical
records and be available on-line in the department to multiple users. The front end Access
system was retained and modified and connected to a multiuser back end server. The system
could then be accessed from multiple terminals (PCs) including portable PCs using wireless
connections in the department.
Once the audit information was being effectively collected the RAH team altered the focus of
the project and expanded the electronic patient record (EPR) elements of the system to
include information sharing with primary healthcare providers. In conjunction with the
Department of Informatics of the University of Wales they transferred the patient information
into Carenet which is an SQL Server database with active HTML generation of information
which can then be viewed remotely over the NHS net by web browsers. Thus information
collected on specific patients in the RAH unit could be viewed remotely by suitable equipped
primary care services.
Current service
The current service operates in the RAH coronary care unit and provides the following
facilities;
57
1.
Patients presenting with chest pain are registered on the CCU system by copying
demographics from the hospital PAS;
2.
Standardised screen based protocols are then completed with the essential medical
information – these protocols are based on previously used paper proformas
3.
Information is entered on patients on a daily basis using a wireless LAN connected PC
taken on the ward round. Again standard screens based on previous paper records are
completed including results of relevant investigations, free text consultant’s opinions and
structured nursing reports
4.
Patient specific information can be viewed in any one of 8 local GP practices using
standard web browsers accessing Carenet over the NHS net.
5.
Analysis of aggregate data is available showing the unit’s performance in dealing with
patients presenting with unstable angina and myocardial infarction
I was able to watch the system in use during a ward round during my visit and was very
impressed. Perhaps the most obvious comment is that it actually works and is used
enthusiastically by nursing, junior and senior medical staff and has already to some extent
replaced handwritten records. I got the impression that the EPR is the primary method of
communication between the multi-disciplinary team looking after the patient rather than the
handwritten notes although there is still considerable record duplication.
There are some obvious functional limitations of the current system which include;
•
Lack of timestamping and electronic signatures by the individual users
•
Lack of order communications (including the status of such orders) and results reporting
to and from other information sources such as electrocardiography, echocardiography,
pathlology laboratories etc
•
Lack of ability to create or embed letters (referral from GP, local outpatients and
discharge summaries) in the EPR
Inspite of the limitations the system has achieved its primary objective of delivering effective
clinical audit information and providing a shared (although limited) record within the
department and with the referral source.
The Application for funding to expand the RAH system
The RAH team have submitted a proposal to the Scottish Office for a modest development of
the system. The proposal includes plans to;
1.
Expand data entry to include completion of chest pain protocols in A&E before admission
to the cardiac unit
2.
Add knowledge based decision support to the management of patients presenting with
chest pain
3.
Add the ability to view ECG data held on a ‘foreign’ database
4.
Improve the ability to create and maintain a common multi-disciplinary clinical record
5.
Add the ability to create letters (such as the discharge summary) within the EPR
6.
Link the British National Formulary electronically to the EPR for drug prescription and
drug interaction
58
7.
Create the ability for primary care providers to generate an electronic referral letter within
the EPR
8.
Create the ability for tertiary care providers to view and contribute to the EPR and in
particular enter the results of coronary intevention for those patients referred by the RAH.
The RAH team have requested funding of about £142K for a 3 year project based on the
existing team.
Comments on the future project
Scope
The RAH team have created a valuable asset (an EPR incorporating audit information) and I
believe they now need to focus the project on those elements which will deliver both improved
hospital wide communication, communication with primary and tertiary care providers and
hospital savings in terms of medical records management.
Specifically I think they should concentrate on the following developments;
1.
Incorporation of all letter writing within the EPR. At present secretaries within the RAH
create letters / discharge summaries / procedure reports / investigation reports using
personal productivity tools on PCs which then generate paper records. This should be
changed so that all such communications are generated within the EPR improving
internal and external communications are reducing the dependence on the paper record.
This will also have the effect of making the ‘cardiac’ project a ‘hospital’ project.
2.
Continue to develop communications with the primary care providers making it possible
for local practices to see the letters / discharge summaries / procedure reports contained
within the EPR and to generate their own comments and referral letters
3.
Extend access to the EPR to those centres providing tertiary services to the RAH and try
and encourage them in turn to contribute electronically to the EPR
4.
Continue to develop protocols for audit based structured data capture both within
cardiology and with other medical disciplines within the RAH
5.
Develop order communications and results reporting within the EPR so that an audit trail
of requests and their current status can be examined and so that service departments
within the hospital (such as radiology and pathology) act as clients to the EPR bearing
responsibility for their systems to contribute results of investigations to the EPR
Management
My discussions both with the RAH project team and the hospital management highlighted a
number of expected issues. The RAH cardiac project has been created and is run by a small
team from within the cardiac department. Whilst the hospital has supported and co-operated
with the project, it is not viewed as a ‘hospital’ IT project and there is anxiety in management
about project control and its effect on the hospital. The management do, I believe, understand
the potential value of the project to the hospital. I believe the hospital management will
enthusiastically back the project if given the opportunity to become fully involved.
I recommend that;
1.
The RAH cardiac project is recast to become an RAH mainstream EPR project. The
hospital trust board should create a project advisory board to include the original creators
of the project from the cardiac department, other clinical disciplines, hospital
management, the hospital IT director and external advisors from the Scottish Office.
59
2.
Consideration should be given to making the chairman of the project board a member of
the main hospital trust board
3.
The Project advisory board should recruit (or internally appoint) a project manager who is
responsible with the project team for carrying out the policy of the project advisory board
4.
The project team should remain organisationally and financially independent from the
main hospital IT department
Technical considerations
The technical infrastructure of this project is sound. It is highly likely that in the medium term
EPRs will be based on hypertext documents and that by using a front end to populate a
database which actively generates HTML the project is largely future proofed. Equally by
basing communications TCP/IP the project has selected a stable long term communication
standard.
It probably does not matter what type or types of front end data capture systems are used
providing the information ends up in a web browsable and web editable database which can
be distributed.
I would however make a small number of technical comments;
•
Internal data security in the current systems is weak in that data / documents do not carry
electronic signatures or access control lists.
•
Data should be encrypted (using asymmetric encryption) both when stored and
transmitted. This would reduce reliance on the NHS net which is perceived as unreliable
and slow and would enable data to transmitted over the internet
•
Electronic medical document standards may evolve into using XMI/XML rather than
HTML.
Conclusions
1.
Electronic patient records are going to be developed and be in widespread use within 10
years. Their beneficial impact on the cost and quality of care cannot be overestimated
2.
A prototype EPR has been developed at the RAH based initially on the need for clinical
audit and subsequently on the need to communicate between the secondary and primary
care centres. Both driving forces for EPR development are entirely valid
3.
Most of the technical infrastructure used by RAH (internet standard communications,
relational databases, active web pages and browser viewing) is entirely appropriate and
as far as possible future proofed by today’s standards.
4.
The RAH development at present lacks the necessary structure and control for
widespread dissemination and is currently limited to a single medical domain
5.
I believe that the RAH system can be developed into useful EPR driven by the need for
rapid communication between primary and secondary care and clinical audit.
60
6.
I believe that the RAH setting of an ambitious secondary care DGH with a young and
motivated team is probably the ideal environment for such a development which would
get bogged down in a tertiary academic centre
7.
The RAH application for future development could be recast to reflect the primary needs
of rapid communication of letters and discharge summaries in more than a single medical
domain as well as satisfying the needs of clinical audit in multiple medical domains
8.
The RAH application should be developed to reflect the need for more formal
development control involving the RAH trust board
9.
I believe that an expanded RAH development should be strongly supported by the
Scottish Office with the defined objectives of
•
Producing an hospital wide EPR incorporating all patient based letters / summaries /
reports
•
Enabling secure remote access to the RAH EPR from primary and tertiary centres
•
Enabling contribution to the EPR from primary and tertiary centres including referral
letters and reports
•
Encouraging the development of clinical audit spanning primary, secondary and tertiary
care by incorporating the necessary data capture tools within the EPR
Appendix A
My thanks are due to all the RAH cardiac department staff especially those who gave up time
to be interviewed. These included;
Dr Iain Findlay – Consultant Cardiologist
Dr David Cunningham – System designer
Mr Jim Bretherton – Adult Medicine Directorate Manager
Ms Janey Sommerville – Database Designer
Dr Alan Harkness – Atheroma database designer
Mr Alan Blackburn – Deputy IT director
Mr Mark McPhail – Medical Physicist
Sister Doreen Palmer – cardiac unit
61
Sister Sandra Blades – cardiac unit
62