Yorkshire Centre for

Health Informatics

Update on Health Informatics in the UK

Dr Rick Jones

12th June 2013

r.g.jones@leeds.ac.uk

Outline

• Historic Context

– What went wrong with the National Programme for IT

– What went right

• What is happening regarding:

– Scalability

– Standardisation

– Interoperability

• The Research Opportunities

– CPRD

– ResearchOne

National Audit Report – June 2013

• In a note for the Commons’ Public Accounts Committee, the NAO says that 98% of estimated benefits of the London

Programme for IT, the South Programme for IT and the

Electronic Prescription Service and Summary Care Record programme, were still to be realised at March 2012.

• The note, which reports on a much-delayed review of the benefits of the programme demanded by the PAC when it

investigated NPfIT in August 2011, says that in March 2012, the DH put the total cost of the programme at £7.3 billion

with total benefits at that point at £3.7 billion.

• It estimated that by the end of the programme (between

2016 and 2024), the total costs would be £9.8 billion and

the benefits £10.7 billion.

Historic Context

October 2002

April 2005

September 1998January 2001

June 2002

April 2013June 2012

Pro

vid

e P

rescriptions

Serv

ice

Build

Life-long H

ealth

Record

Serv

ice

Pro

vid

e B

ookin

gs

Serv

ice

Pervasive national electronic infrastructure (N3)

2002

1994

1998

IM&T Strategy for the NHS

What went wrong?

Programme Scope - 2002

100%

50%

Daily

usage

Pro

vid

e P

rescrip

tio

ns S

erv

ice

Pro

vid

e B

oo

kin

gs S

erv

ice

Bu

ild L

ife

-lon

g H

ealth

Re

co

rd S

erv

ice

Pa

tien

t C

ho

ice

Dig

ita

l Im

agin

g

NH

S N

um

be

rs f

or

Ba

bie

s

Se

cond

ary

Use

s S

erv

ice

NH

S E

ma

il S

yste

m

Tra

nsfe

r of

reco

rds b

etw

een

G

Ps

Qu

alit

y M

ana

gem

en

t

Ana

lysis

Syste

m

Bo

we

l C

an

ce

r S

cre

enin

g

Pervasive national electronic infrastructure (N3)

0% 0%

100%

50%

Pro

gre

ss

Pro

gre

ss

1.4m

prescriptions

43,000 bookings

4.2m

enquiries

43,000 bookings

2m new images

2m new records

5m

messages

5,000

transfers

£750,000 paid

1,850 babies registered

8,000 screenings

Daily

usage

Original Scope Additional ScopeKey:

Commissioning Payment by Results Plurality of provision

What went wrong?

Programme Scope in 2010

Implementation disaster

• Working with suppliers to implement new systems and services in planned phases

• National Application Service Providers are responsible for purchasing and integrating IT systems common to all users nationally

• Local Service Providers (LSPs) will deliver IT systems and services on a local level for regional clusters of strategic health authorities

• LSPs supply and integrate systems to perform functions in the local setting and to interface with the national system

Accenture bailed

out 2006 - £1bn

loss

CSCA failed to

deliver Lorenzo

2006 - 2012

Accenture bailed

out 2006 - £1bn

loss

CSCA failed to

deliver Lorenzo

2006 - 2012

Fujitsu IDX out 2008

Cerner struggling in

South

Fujitsu IDX out 2008

Cerner struggling in

South

London chaotic

& competitive

London chaotic

& competitive

Big corporates failed to recognise

Healthcare vs Industry differences

Differences

• Management

– Unified in most sectors, but health care has clinical and operational reporting.

• Customer

– Clear customer in most sectors, but health care involves variety, including clinicians, payors, government, service providers, and users.

• Variants

– Few industries exceed tens of thousands of variants. Health care typically caters to many tens of millions of individuals.

• Preference and choice

– Most industrial systems have hard metrics. In health care, people’s feelings and choices matter, too.

Similarities

• Process orientation

– All sectors seek improvement in quality, cost,and delay through integrated processes.

• Center of attention

– Health care is becoming patient-centered, following product-centered and customer centered success in other sectors.

• System integration

– Although health care systems are typically larger, more complex, and employ more people than other systems, they still benefit

Avison & Young, TIME TO RETHINKHEALTH CARE AND ICT? COMMUNICATIONS OF THE ACM June 2007/Vol. 50, No. 6

Why is healthcare difficult?

Multiple non-co-terminosity?

HB

A&C HB GGHB

HB

HB

Multiple non-co-terminosity…for the patient’s record

Primary Care

Secondary Care

Community Care

Tertiary Care

Geography

Patients’ records

(on an EPR?)

Lack of insight:

Development Scale

• Group

intercommunication

formula: n(n − 1) / 2

• Example: 50

developers give 50 ·

(50 – 1) / 2 = 1225

channels of

communication.

Outline

• Historic Context

– What went wrong with the National Programme for IT

– What went right

• What is happening regarding:

– Scalability

– Standardisation

– Interoperability

• The Research Opportunities

– CPRD

– ResearchOne

Despite this many things have been

achieved:

• Universal electronic primary care record

• CPOE now common place

• PACs universally delivered

• National Summary Care Record on 50% of population

(25,512,399 citizens)

• Expanded access to knowledge and information e.g. MapOf

Medicine.

• Nascent patient access to their own records

• etc

New Coalition Government

May 2010

• By July published NHS White Paper

• Fundamental changes to NHS structure and processes

building on previous reforms

• Focus on patient information, choices and outcomes

• Predicated on interoperable information systems

New Structure of NHS

Department of

Health 2012

Consistent with 2009 change of

plan: NHS ‘App Store’

Interoperability Toolkit

In reality this is a long way from an App Store

Example: National Laboratory

Medicine Catalogue

www.laboratorymedicine.nhs.uk

What is in NLMC model

• Fully specified test request name

• Test Display name

• Alternate names

• Valid collected specimen type

• Patient pre-conditions

• Attributes that indicate

topography, laterality

and/or morphology

• Additional information to

ensure appropriate test

• Method of Collection

• Analysed specimen types

• Principle of analysis

• Units of Measurement

• Reference Ranges

• SNOMED CT coding of

content.

• Can consume LOINC

• Links to decision support materials and care

pathways

Foundation Data Services

Data Architecture

Data

Standards

Metadata

Models

Data

Models

Rule Models

Data Management

Result

RepositoriesNLMC Knowledge

Sets

Business Services

Orders &

Results

BenchmarkingLab 2

Lab

Knowledge

Support

End User Functions

Order

Comms

Planning

Contracting

EHR

Support

Laboratory

Handbooks

Performance

Management

NLMC Conceptual Architecture

Outline

• Historic Context

– What went wrong with the National Programme for IT

– What went right

• What is happening regarding:

– Scalability

– Standardisation

– Interoperability

• The Research Opportunities

– ResearchOne

– CPRD

Electronic Point of Care (EPOC)

paradigm in e-Health research

• Extending the principles of supply chain automation and electronic point of sale (EPOS).

The ResearchOne Project

Big Data?• 27 million patient records on SystmOne database

• 120,000 active users, over 4,500 healthcare units

• Shared patient record - Primary & secondary care

• Centralised model in CfH-accredited data centres

• 640 million transactions per day

• Top 3 databases on Microsoft SQL Server

Permanent registered GP

patients per census area

Probably the world’s largest EPR?

SystmOne Live

Backup

Live Environment

Data Centre 2

Data Centre 1

Data Centre 1

Iterative

Feedback

Loop –innovation

into

practice

Weekly

ResearchOne Link

ResearchOne

Anonymised Data Extracts

Analytic

work

Public Health

Surveillance

Monthly

John Wright, Born in Bradford

“ResearchOne has the potential to transform

medical research by providing low cost

methods to monitor the impact of exposures

such as air pollution and diet on later health”

Example Projects

• Born in Bradford

– 13,000 families: how genetic, environmental

and social factors impact health. The project

uses Child Health and General Practice data

• Action to Support Practices Implementing

Research Evidence

• GATEway to the Clouds

– Anonymising free text health data

• Improving Prevention of Cardiovascular

Events in Primary Care

• Cardiovascular risk in mental health care

• Public health monitoring

Anonymisation level required

Smith, Xu, Hina and Johnson (2013). GATEway to the Cloud - Case study: A privacy-aware environment for Electronic Health Records research. 7th IEEE International Symposium on Service Oriented System Engineering, SOSE 2013, San Francisco, CA.

Limited AccessAnonymised e-health records for purposes

other than direct care

Researcher

Virtual Research Environments as

Portals onto a Safe Haven

National linkage of all health data -

CPRD

• Clinical Practice Research Datalink Service

• Follow-on from GPRD

• ~£60m funding

• Feeding data to Pharma & Research

• Extracts GP data

automatically via HSCIC

• Launched 2012

Supported by MRC Funded

Research - 2012

Final words – plus ca change.

• Health Secretary Jeremy Hunt told the audience at a US conference that the UK

was in the third stage of technology’s

transformation of health care.

• The government’s plan to sequence 100,000

human genomes and link these to electronic health records will be “as significant as the

founding of the Internet”.

• Minister for Universities and Science David

Willetts said: “Thanks to the NHS and the UK’s world-leading research base, we are

uniquely positioned to use patient data to

study disease and develop better treatments.”

Summary

• UK National Programme for IT was a mixed blessing

– Many failings but several notable successes

• Health Informatics high on research agenda

– ResearchOne

– CPRD - £60

– Medical Research Council

• eHerc Programme - £20m

• Medical Bioinformatics programme - £60m

• All predicated on increasingly large scale, standardised and

interoperable NHS Information Systems