Standard debate

Back in the day, the mantra was “education, education, education”. At eHealth Insider Live 2010, it might have been “standards, standards, standards”.

From an IT perspective, the government’s pledge to free the NHS from bureaucracy and devolve power to the frontline can only be achieved with the underpinning of universally accepted standards.

It is standards, most of those attending the two-day conference and exhibition in Birmingham agreed, that underpin interoperability.

And it is interoperability that underpins the ‘connect all’ rather than ‘replace all’ philosophy for IT systems that was launched 18 months ago, but which has been taken up by the new administration.

It is also interoperability that will enable the flow of information that the NHS will need to deliver the efficiency, productivity and innovation required of it. And, indeed, the new information driven services for patients outlined in the current consultation on an ‘information revolution.’

Standards for new systems

To illustrate the point, Brian James, chief executive of The Rotherham NHS Foundation Trust, talked about its plans to become completely paperless by combining process redesign techniques with new technology; in its case a Meditech EPR procured outside the National Programme for IT in the NHS.

He described how clinical departments had redesigned their systems using the Lean manufacturing methodology to eliminate waste and create ideal pathways.

On these pathways, departmental workflows are being been built that will not only be paperless but deliver significant efficiencies; not least because fewer people will be employed to handle and chase paper.

“The Lean redesign would not be possible without IT so the two things are inextricably linked,” he said.

“So, for example, in May next year – if all goes to plan – out patient processes will be unrecognisable.”

For example, he added: “All out patient notes will be constructed by the system and will be discharged at the point that the person leaves the department and transmitted to the GP at that point.”

The system – which James wants to pay for itself, having ‘hypothecated’ 2.5% off directorate budgets for two years – will require clinicians to abandon free text entry in favour of code. Making the change relies in part on adopting common standards in messaging and in terminology – HL7 and SNOMED.

In the longer term, James wants to see community and GP services linked up, “providing end-to-end paperless system from the GP to the community and hospital services and back again”.

He said: “The main issue is connectivity. Our community services use SystmOne, as do 57% of our GPs. Both systems are HL7 compliant; SNOMED is built on the Read codes. I do not see a major problem.”

Standards for the future

The theme of standards also came up strongly in the UK PACS and Teleradiology Group meeting, where the talk was all about using XDS and XDS-I to join PACS with RIS and both with other hospital and community systems.

It came up in primary care discussions, where the talk was about how GPs can exchange information with acute providers.

It came up in conversation among delegates disappointed by health minister Simon Burns delivering a speech urging them to contribute practical ideas for bringing about the ‘information revolution’ – before dashing off without taking a single question.

Among the questions that visitors had wanted to ask were: How exactly would his plans work when the systems holding the data needed cannot presently talk to each other? And what standards would underpin the vision he outlined?

Interoperability came up, too, at the best-attended and most exciting exchange at EHI Live 2010, which took place between Christine Connelly, NHS director general for informatics, and around 300 conference delegates.

They asked what she intended to do about the “information standards mish mash” and begged for the adoption of international standards; with Tim Benson, founder of the consultancy Abies, urging her to look at creating a single body to oversee them on the Canadian model.

Connelly acknowledged the importance of this, but threw the ball back to delegates: “People say ‘we do not want a big top down exercise and we want you [central government] to get out of the way. Then we hear ‘if the government does not this then we cannot deliver’.

“So we want to hear what is the space that the government can occupy that will enable you to become freer to deliver and innovate?”

Standards from Europe

The same hall had earlier been addressed by Martin Ellis, chair of Intellect’s safety forum, who was banging another standards drum. He addressed the issue of new international standards for software that is used as a medical device.

New regulations from the European Commission have two implications, he said. The first is that a piece of software not previously subject to these strict international standards will become so in future; and that trusts using this software will be responsible for making sure it is safe when it is integrated into wider systems.

At the moment, guidance on implementation is being produced by the Medicines and Healthcare Products Regulatory Agency. And Ellis is concerned.

He explained, for example, how the MHRA has deemed that a patient administration system is not a medical device in these terms, even when it replaces a paper system for issuing prescriptions with an electronic one.

Conversely, an algorithm in a telehealth programme that alerts a professional when a patient requires an intervention is a medical device. No-one is quite sure where a fitness app on iTunes might fit.

The concern is that the standards will stifle innovation by software developers and impose a bureaucratic burden on trusts. On the other hand, there are legitimate safety concerns that must be addressed.

So far, Ellis added, very few people from healthcare IT have become involved in trying to influence guidance. “The healthcare industry needs to be more engaged,” he said.

At the moment, the whole standards arena is up for grabs. Connelly envisages the new NHS Commissioning Board as the organisation to set standards for the NHS, using her as an advisor. As the DH works on the detail over the next year, she is looking to you to provide some ideas and thinking.