Insider View: Jon Hoeksma

The nation’s leading doctors organisation has just given its full-throated backing to efforts to introduce electronic patient records, and announced a partnership with a leading supplier to help spread best practice on health information.

No, that’s not news from a parallel universe, just from America. The organisation is the American Medical Association, a close cousin of our own British Medical Association. But the contrast in attitudes is striking.

Over there and over here

At the beginning of March, the AMA announced an online initiative with Dell to encourage the adoption of electronic patient records. Not ground shaking, but an important supportive message none the less.

Contrast that with the latest announcement from the BMA, which last week very publicly called for the roll-out of the Summary Care Record to be suspended. It even insisted that NHS Connecting for Health cut a video that included a supportive clip from a BMA doctor.

Without a whiff of irony, the BMA said the roll-out of SCR was going too fast, because it was running ahead of a full evaluation of its pilot projects, and perhaps the ability of patients to decide whether or not to opt out.

This, remember, was being said about a national initiative that was meant to have been completed – albeit under another name – by 2006. That has so far rolled out 1.2m records. About a roll-out that will see a further 9m patient records created in five strategic health authorities, including London, over a year at best.

It’s true that in SCR terms, the DH and the SHAs are suddenly moving at break-neck speed. And on the specifics of the department’s inept management of patient opt-outs, the BMA has a strong case.

But who exactly are its more apocalyptic pronouncements meant to serve? Not the doctors, medical staff and patients who will eventually get to use these records, surely?

Two organisations separated by a common ending

Although the AMA and BMA are only separated by one letter of the alphabet, in attitudes to IT in healthcare the gap sometimes appears as wide as the Atlantic.

This is not to deny that many, many individual members of the BMA are terrific advocates of clinical technology and local champions. The vast majority of doctors want the best information tools possible to support patient care, and are just frustrated at the slow pace of progress.

Unfortunately, the BMA, which is by far the most influential national body representing the views of doctors, appears at best lukewarm about the benefits of NHS IT.

Corporately, it has not unequivocally put its full weight behind efforts to digitise the health service; separating the desirability of this objective from specific concerns about a given policy or specific implementation approaches.

Instead, it has too often vacillated, acted as a platform for narrow sectional interests, or left that platform to clinician politicians with an axe to grind. Given that the whole practice of medicine is based on innovation and communication, the attitudes of these nay-sayers to ICT in healthcare can appear bizarre.

Something under the record is lurking

Although they are rarely voiced as such, many objections stem from seeing technology as a Trojan horse for reform of the health service that those voicing them don’t like.

Publicly, GP criticisms of the current SCR roll-out campaign are based on fears that the database won’t be secure or that it might be misused, and that patients have not been adequately consulted or given easy enough ways to opt-out.

But behind closed doors – and on closed online forums – a less altruistic fear is being voiced, namely that GP livelihoods and professional responsibilities will be threatened if access to their records is enabled by electronic links, because new providers will be able to come in and do some of what they do.

Clearly, a tranche of doctors have a deep mistrust of the government and its motives, together with genuine fears about the future of patient care. Against this backdrop, it is imperative that the BMA does not use opposition to electronic patient records as a proxy for opposition to other aspects of health policy.

Consistency is all we seek

The BMA has adopted entirely contradictory positions on the National Programme for IT in the NHS within an 18-month period. In 2008, the doctor’s union called for the whole programme to be scrapped.

But at the end of 2009, with the Treasury sharpening the axe, the BMA unexpectedly swung behind a clearly relieved secretary of state for health, Andrew Burnham, endorsing the programme. Dr Grant Ingrams, chair of the GP Committee’s IT subcommittee, said savings would be better made elsewhere in the NHS.

"The way it was procured years ago was wrong, and could have been done better – but now it’s getting to a point where it’s likely to be rolled out very soon,” he argued. Now a bit of the programme is actually being rolled out, the BMA wants it stopped again.

Back new clinical champions

Clinicians like Dr Gillian Braunold and Dr Simon Eccles have been great individual champions for clinical IT, but they are closely associated with the national programme. A new wave of clinical champions is striking by its absence in the UK.

At a local level, very few trusts have clinicians in full-time IT leadership roles, explicitly acting as local expert champions and advocates. Instead, being a clinical champion is often an add-on to a full-time clinical position, or project-based.

Given the relatively small number of chief information officers in NHS trusts, and the lack of a well defined and attractive career path for clinical IT leaders, this is hardly surprising. Yet again, contrast this with the situation in the US, where a new breed of clinician and IT leader has been carefully cultivated over the past ten years: the chief medical information officer (CMIO).

These prized individuals – who span both the medical and technology realms – have been identified as essential to the success of complex clinical implementations and cultural change. From an almost standing start five years ago, nearly 25% of all US hospitals now have CMIOs, with a wide variety of dedicated education and training programmes now in place.

There is a real opportunity for the BMA to exert its leadership and help shape the development of a new generation of clinical IT leaders. It is an opportunity it should embrace.