Editorials

Electronics, clinicians, and the NHS

The patient electronic record needs financial and professional support

Information in practice pp 875, 878

Clinicians in the United Kingdom are accustomed to false dawns in the technology and management of clinical information, but, for once, real change might happen. In this issue (p 875) Keen and Wyatt discuss the changes in electronic networking and the errors that were made before clinicians got their hands on the process.¹ Fortunately, not only is the network changing, but so are its associated technologies.

Clinicians need the network to carry the electronic patient record and at last we can visualise both the possible shape of the record and how it might work for us. This accessible, private, active record is a great prize, but gaining that prize is hard. In terms of clinical informatics, the NHS now faces the task of moving from information islands of varying quality to a congruent linked community where data can move freely and be used to create helpful knowledge for clinicians beyond the capabilities of any paper record.

As a backdrop, we have the bullish approach of governments with the information management and technology strategy in 1992 and Information for Health in 1998 (being relaunched this month). ^{2 3} These both proposed that a UK electronic NHS was just around the corner. In both cases the reality lagged far behind; the software to support the proposed electronic architecture did not exist, and neither did the hardware in primary or secondary care.

The training and preparation for culture change had (mostly) been a joke, and networking was lost in a swamp of inappropriate standards and bad contracting. System suppliers had little to be proud of either, with their protectionist commercial urges hampering the move towards open standards and platforms. The death knell for useful progress was that governments were keen to encourage, but not to fund, the essential work necessary to stop us simply replicating paper records in an electronic form.

Meantime, a generation change has occurred whereby no doctor now finishing postgraduate training is puzzled by the internet, and the exponential growth in business use of the medium has bred familiarity, if not love, among even those most resistant to change. Change is suddenly inevitable, and occurring.

Crucially this summer, the English General Practitioners Committee announced that the NHS Executive's plan to place free personal computers connected to the NHSnet on every general practitioner's desk had finally been approved, coinciding with similar Scottish initiatives that are also discussed in this issue (p 878).⁴ This finally buried the government's illusion that general practitioners should pay for information technology for the NHS, a concept about as logical as making nurses pay for patients' dressings. Renamed Project Connect, this plan offers a level playing field for general practice and primary care information technology, without which an electronic NHS will be impossible. It is a cruel twist of fate for the UK Department of Health that the Treasury has delayed implementation on the grounds of the business case not being proved, thus showing that it is not only clinicians who suffer quixotic decisions in health care.

The next link is that in September the department announced at an informatics conference that it is to legitimise electronic record keeping by general practitioners. Although this move threatens to produce "paperless" practices rather than practices with competent electronic patient records, it will stimulate the profession to demand the ability to transfer records from one general practice to another.

Even if transfer had been possible before, then the absence of a working clinical coding scheme to bring the record to life has been a major hindrance to the wish to connect up. The news that the SNOMED CT clinical coding scheme is running to time with no major problems is immensely encouraging.

When transfer occurs, it can occur over an NHSnet which is now restructuring to use the dominant internet standards and which is truly capable of moving traffic in from and out to the internet. This is in line with the needs of clinicians after long, and eventually constructive, dialogue with the NHS Executive.

And when clinical information is transferred, to be of use to patients and doctors, it needs guaranteed integrity and privacy. The recent procurement of (scalable) cryptography for pathology test result messaging, and the forthcoming strategy for cryptography, means that secure transmission of patients' data will be possible within the NHS sooner than expected.

When this kind of information moves around, it must be about the right person and delivered to the right place. For that, it requires the National Strategic Tracing Service to guarantee identity, and NHS Directory services for addresses. Both these are moving ahead on a timetable to match the preceding developments, and in line with the wishes of clinicians.

Finally, to control its immense versatility, electronic information must have standards or else it will generate garbage. The formation of standards boards, driven by clinicians, for clinical, technical, and management information are all encouraging moves underpinning the quality of the change from paper to electronics.

The critical risk now is the level of commitment from government. The electronic record is financially a speculative venture, not a profit and loss entity, but its arrival is inevitable. Securing and supporting this development work is what clinicians now need. The government must make the commitment to provide resources for this, or the NHS faces another lost decade.

Grant Kelly, general practitioner. 

8 Lavant Road, Chichester, West Sussex PO19 4RH