Overview of EHRs in the United Kingdom
Adistinguishing feature of healthcare in the United Kingdom is that it is essentially free to the patient at the point of service. The U.K. government is charged to design, manage and fund a centralized healthcare system that addresses every aspect of care delivery including office visits to a general practitioner, hospital services, outpatient treatment, prescription drugs, in-home care and social services. An EHR in this context is the fundamental information source and flow, crossing organization boundaries, reflecting the life of the patient and the life cycle of their healthcare. Such an EHR must collect and manage patient demographic and medical information in consistent ways so that it can be combined and analyzed with provider information to ensure that the right care is delivered in a connected manner, providing the optimal outcomes for the patient. Information on episodes, treatment and outcomes becomes part of the real time planning, management and funding that is emerging as an essential element of health system management.
The underpinning technology that supports the EHR must be seen to be secure and interoperable to permit accessibility of the information to a broad base of staff that supports patients across all sectors of health and social care. The goal of a population- wide, comprehensive, interoperable EHR is not yet a reality. Citizen EHRs have been accepted by the E.U. as a standard to be achieved in all European countries regardless of their funding model or infrastructure, which most countries are seeking to achieve in their own ways. Whether or not it will eventually be implemented in all its glory or sustained over time is not yet known, but it represents a direction of travel towards a patientcentric, connected healthcare approach reflecting the demands of modern healthcare.
Three critical factors or principles make a broad, comprehensive EHR possible:
- Making information available;
- Making people accountable for healthcare delivery and performance; and
- Linking results with rewards.
The United States faces a significant challenge to progress against these principles in a universal or national way due to the fragmented health market; this will make development of such a broadly defined EHR very difficult.
EHR Reflects Social Policy
An EHR is only part of the tool kit required by a modern, population- wide approach to healthcare. Far more fundamental has to be the definition of the healthcare direction and priorities established by the government or purchasing body on behalf of its citizens or members.We must determine what we as a community believe is right to offer our members in terms of healthcare. To what standards of access, quality and outcomes will we strive? For example, should we deliver care funded by taxes or other social funding that costs the patient nothing at the point of service, or should the costs be borne by insurance, employers and/or employees? The answer to these questions determine the model of care a plan for how care will be delivered, where and by whom. After that must come a logical model or model of information. Who needs to know what so that healthcare can be delivered in the manner we have defined? Which items of information need to be combined in order to run the health system weve just described? Once those determinations are made, the technical architecture is designed and built to support the logical model.
It is this logical and hierarchical approach that drives the sources of funding and how the money will be spent.
of funding and how the money will be spent. Once weve determined that we are going to deliver care to everyone in our community, regardless of income, actions must deliver on that promise. If patients cannot afford cars to drive to a local hospital, means must be found to get them there or the care to them.We must set up a method of care delivery that is both affordable to the nation and accessible to the individual. In the years to come, care of chronic disease is going to become a larger proportion of healthcare. Patients will need access to a broader range of services from a much wider network of service providers. Information must be accessible and exchangeable among patients, physicians, nurses, clinicians, social workers, welfare workers, public housing workers and others, because all of them have a part to play in keeping clinically ill people as healthy as they can be and at home.
Overview of the U.K. Healthcare System
Several years ago, the United Kingdoms National Health Service (NHS) set out a vision of a health service fit for the 21st century. The plan recognized that although the NHS has delivered major improvements in the nations health, it still falls short of the standards patients expect and staff want to provide. In particular, survival rates in the U.K. for diseases like cancer and heart disease were below those in many other countries. There were long waiting lists for people needing medical service, and availability of certain treatments and medications had become a post code lottery. This failure to meet patient and staff expectations was exacerbated by an increase in demand for healthcare, changes in medical knowledge that make possible more complex and expensive treatments, an acute shortage of doctors and underfunding of healthcare services.[1] Adding to the problem, the NHS remained until recently a system lacking national standards or clear incentives to improve performance. It perpetuated old-fashioned demarcations in staff and barriers between services. The NHS further suffered from a complex mix of centralized policy and priority setting with a semi-autonomous local management capability and disempowered patients.
An independent review of the NHS concluded that, in order to meet peoples expectations and deliver the highest quality care over the next 20 years, the U.K. would need to devote more resources to healthcare, and implement corresponding reforms to ensure that all resources are used effectively. The review also called for doubling the previous spending on information and communications technology to support the new healthcare model. The strategy will enable NHS professionals to have the information they need both to provide that care and to play their part in improving the publics health. The strategy also aims to ensure that patients, caregivers and the public have the information necessary to make decisions about their own treatment and care, and to influence the shape of health services generally.[2]
During the last 10 years, the health system in the U.K. has established the legitimacy of access to clinical information, performance comparisons and minimum standards. Though access is still imperfect and incomplete, patients can, for example, review the activities and current standing of their local hospitals and compare their performance against national standards. The scrutiny based on the reimbursement and clinical audit process requires physicians in family practices to report the treatments they have prescribed based on their diagnoses and to evaluate their effectiveness. They increasingly receive guidance on leading medical practices and which drugs or therapies are recommended by government-sponsored organizations. A national strategic framework spells out what kind of care is appropriate for key disease groups. Diabetics know in advance what type of care they should expect. Cancer diagnosis and treatment, where time can be a critical factor, must meet specified time constraints.
These care requirements and acceptable wait times are built into the performance measurements for medical practices and public hospitals. For example, it is now required that a family practitioner be able to offer a patient an office visit within 48 hours of receiving the call for an appointment. Emergency rooms must see walk-in patients within four hours. Providers are monitored and evaluated partly on their ability to meet these time requirements. Providers report their compliance with access guidelines and other performance metrics to their funding authorities on a regular basis. Since performance is linked to rewards and payment, hospitals that experience a slip in performance will experience a commensurate slip in payment. Hospitals are currently rated using a star system zero to three stars. A three-star hospital gets access to more money and more selfdetermination than fewer-starred hospitals. A zero-star hospital faces the potential of government-mandated replacement of its chief executive and management team.
At this point, the U.K. is also ahead of many other countries in articulating a social policy for healthcare delivery and for spelling out in detail what constitutes an acceptable level of care for its citizens. Ironing out the details is a continuing challenge, but the general direction is well-established. Other countries are ahead of the U.K. in investing in infrastructure the unglamorous, uninteresting and largely invisible information and communications technology by which the information in the EHR is stored, managed and exchanged. However, the U.K. government is involved in establishing mandatory standards for interoperability among local systems and for funding the implementation of a national network in England.
A goal of the NHS, toward which some component parts are already in place, is to make the general practitioner more central to the whole patient journey. General practitioners can stay in control of what happens to each patient, because the information is visible to them. A GP can make appointments electronically, order tests and review the results online, view the hospital discharge of patients, schedule aftercare and manage services for chronically ill patients.
Challenges
In the U.K., as in the U.S., getting physicians to adopt and use an EHR and its associated computerized functions is difficult. Adapting to a computer-based environment is not a technical issue; the challenge is managing change. The EHR must be designed and offered in such a way as to ensure that clear benefits are achievable for physicians and other clinicians, and those benefits must more than justify the learning curve and the occasional inconveniences of communicating electronically. Clinical staff need to become involved early in establishing practice guidelines and standards of care. System designers and implementers must work with physicians and other clinical stakeholders to develop advantages early to build up momentum for change. It is counterproductive to try to force doctors to behave in certain ways. Rather, physicians need to collaborate with other stakeholders to support policies and practices they recognize as acceptable levels of care. All stakeholders need rewards and motivations aligned with the success of the EHR.
The existence of an EHR bends the envelope of privacy rights. Though different countries have different standards of privacy, the need to define a standard of privacy and adhere to it is universal. In the U.S., HIPAA precludes the use of a patients Social Security number as an identifier. In the U.K., the government has adopted the policy of standard identifying numbers for every patient. This simplifies the process of matching the patient to his or her medical, demographic and financial information. An EHR is evidence of the value of joined-up information and equally a target for those uncomfortable with the concept that their information is not in their immediate control. The same levels of sensitivity dont seem to be applied to banks which know about our money, schools which know about our children or loyalty card companies which know about our lifestyles. The irony is that the people most concerned about patient information security are people who are healthy. Sick people are less concerned about information security. They want to get well. The debate about security and confidentiality is driven by informed, healthy people.
As a practical matter, not all services are available in every hospital and every geographic region. A standard that calls for referring a patient at a certain point in treatment to a physical therapist is not applicable if the community lacks the specified resource. Localization of national policies and standards is necessary for an EHR to be useful. As an approximation, though it is not desirable for every hospital or physician to reconfigure the EHR, the system must be flexible enough so that providers serving local communities can use at least 70 percent of the system that applies universally and modify up to 30 percent to local needs.
Patient and Population
The overall health of a population is well-served by a successful EHR. An EHR is a good tool for discovering the best possible health outcomes for tax dollars. It gives quick access to a large amount of patient data and tools that can compare and analyze these data to inform decisions on a population level. Imagine that every hospital and every general practitioner in the country has access to a nationwide EHR and that every patient has a unique identifying number. Using only those numbers leaving out patient identities patient information can then be simply aggregated into a large, valuable database, which grows larger and more current daily because every day people have more and different health-related activities. Its then possible to track what medications patients are on, what hospitals theyre in and what their health outcomes are. Interrogating such a database could tell us that there are 3,000 diabetics in the London area, for example. It could tell us how often they were admitted to hospitals and for what conditions. It could tell us how long each patient stayed in the hospital and whether that patient was readmitted within the next year. If there are variations from region to region or physician to physician, investigators could work out the extent of the variations and potentially determine what caused them. They could discover, for example, whether improved outcomes were tied to different medications, different treatment options or other factors. This information and analysis can help direct how to spend public money to get the best possible outcomes. Right now, treatments can only be tied to surrogate markers activities which indicate the condition of the patients health. Eventually mechanisms tying medical interventions to quality of life will further enhance the value of population studies made possible by an EHR.
A Long Journey
Implementing an EHR on any reasonable scale is a complex and expensive undertaking; too challenging to make false starts. It would be madness to switch off existing systems and start at square one. Start where you are. It matters little which technology you choose, because none are perfect. Start by changing how you treat patients; change it until it looks close to what you think you want to offer as a service. Join together service components and processes, even if the supporting technology is old, cobbled together, supplemented and patched up. Whats vital is to establish a direction of travel and migrate gradually to a set of services which are robust, integrated and based on a single platform and single logic. The commitment is to the migration and to never again invest in products or services that are inconsistent with the journeys architecture and direction. This is a change in strategy from implementations based on products that are complex, proprietary and built on vertical logic. An integrated solution, scalable, flexible and based on horizontal logic, is a much better migration objective and more reflective of the patients journey.
Summary
The single point of logic for an EHR has to be the experience of the patient. Previously the single point of logic in hospital systems was the experience of the physician. As recently noted in a speech by Professor Richardson of the Great Ormond Street Hospital for Sick Children, physicians today are gatekeepers at the temple of medical knowledge. They decide who to let in and what information to share with patients. In the future, physicians will be more like guides or advisors, sharing access to information and assisting patients in making better, more informed choices about their medical care.
The EHR must facilitate that evolution. It must support the experience of patients who will accrue the health benefits. Otherwise its an interesting diversion not worth the expenditure of tax dollars.
The EHR is an expression of what we as a society believe healthcare should be today. Its practices and technology should exemplify those beliefs and evolve towards what we hope healthcare can become tomorrow. It must enshrine the changes we chose to make.
Endnotes
- Health at a Glance OECD Indicators 2003 briefing note (United Kingdom).
- An Information Strategy for the Modern NHS 1998-2005, A national strategy for local implementation; NHS Information Authority 1998.
