Choose and Book faces potential “show stoppers”

One of the pilot sites in Barnsley is understood to have put a freeze on using the main CaB application due to concerns about data privacy and consent issues. 

The problems were first reported yesterday by the Sunday Times which stated part of the CaB trial “had been halted due to fears that patient confidentiality may be compromised". 

The National Programme today issued a statement refuting this report, stating: “… pilot activity to trial Choose and Book in a small number of ‘early adopter’ sites across the country is continuing and bookings are being made by all the early adopters including Barnsley."

E-Health Insider has been told by a well connected source that, while activity was not halted in the way the Sunday Times suggested, the Barnsley site was not using the main integrated CaB application.  Barnsley, together with the two other pilot sites at Haringey and Harrogate, is instead understood to be using a basic, stand-alone non-integrated web version of the CaB system, described by one source as “hand cranked". 

This non-integrated, stand alone web system is said to include no links to patient demographics or medical records, requiring users to re-key this data.  This “naked" eBooking application was introduced in June when it became clear the integrated CaB service would not be ready to go live in July.

A national programme spokesperson confirmed to EHI that a stand-alone web version of Choose and Book was currently in use: “The introduction of a web-based referral service is an essential part of the phased implementation of the Choose and Book service and is not an interim solution."

The spokesperson added: “An integrated Choose and Book service is available. It has been tested and it works." No indication was provided though on when it will be made available outside test environments.

Explaining why sites have not yet got the integrated CaB application the NPfIT spokesperson said: “It has not yet been made widely available to GPs and that is in line with carefully developed implementation plans under which there will be a gradual roll out according to an organisation’s readiness to implement."

Even with the “naked” stand-alone eBooking tool the total number of successfully made electronic appointments remains extremely small.  At the beginning of September Computing magazine reported that since July “fewer than 10 bookings have been made using the online hospital appointments system".

Barnsley is understood to have deferred using the main CaB application after identifying a list of 22 outstanding critical issues with the system.  A source who is familiar with the list told EHI that “eight or nine of them are potential show stoppers".

EHI understands that the biggest issues identified in the list, which has been sent to NPfIT’s national CaB team, concern patient consent and the way in which the system issues a Unique Booking Reference Number (UBRN).

The reported problems with patient consent focus on the way the NHS data spine, the database of patient demographic details and eventually of summary medical records, enables patient’s consent details to be amended by users without a legitimate relationship. 

A key part of the NPfIT’s approach to consent is that each patient sets a flag on how they want their medical record to be shared and whether it should go to their spine record.  The flag can be set as agreed, implied or denied consent.

Reportedly though, early users of the integrated CaB Book system found they could change the consent flag status on any patient.  The industry source told EHI: “You can log-on to any patient and change their consent flag and access that patient’s demographic record, even if you do not have a legitimate relationship with that patient."  Such actions would, though, leave an audit trail back to whoever made the changes.

The UBRN issue also indicates there are problems with the current design of the system.  The industry source told EHI “The UBRN is a fundamental issue in the primary care end of CaB, as it issues a number before a doctor has made a speciality selection or booking, or a referral letter being issued".  In effect this means that the UBRN can float in the system, without being attached to a patient or booking.

An NPfIT spokesperson stated: “The new arrangements will be much more secure than current practice where paper records and letters are sent through the post, and sometimes left accessible in public spaces."

EHI understands that the national CaB team have accepted that the approach to issuing the UBRN was flawed and has since issued a change control notice to Atos Origin, the firm responsible for delivery of CaB.  

The £65m CaB scheme is scheduled to be the first service from NPfIT that patients will see, and is essential to the government’s stated objective to have a fully booked NHS by the end of 2005. 

The system was due to build up from pilot sites after July 2004, and although initial bookings were confirmed by NPfIT, the programme has since declined to provide updates on numbers of bookings made or the number of sites using the service since.

Primary care systems suppliers now accredited to connect to the national CaB application include EMIS, Seetec and In Practice Systems. EHI put a series of detailed questions to NPfIT on the reported problems with Choose and Book, and will publish any full response received.