The way of the dragon

Centrally funded and driven IT projects may be taboo in the NHS in England, but they continue to determine the direction of travel in Wales.

Of course, there are considerable differences between the two countries and their health systems. The mere size of Wales makes a centralised approach manageable, with its population not even half that of London.

Wales has also removed most of the internal market that is being reinvigorated in the NHS in England, so there is, arguably, both more space for central planning and for co-operation on the ground.

Even so, the NHS Wales Informatics Service not only believes that it is heading in the right direction, but one that is supported by the seven health boards in the country.

Talking to eHealth Insider at its Swansea Research Labs, Dr Martin Murphy, clinical director of NWIS, says that when it embarked on its multitude of IT projects the situation was quite different.

“When we started in Wales, we came in and found a situation where health boards had done their own thing; they had different systems and nothing was interoperable.

“The hospitals were quite a long way behind GPs, so the first thing we did was get people together to decide what the future strategy should be, which we did successfully.

“But Wales is small enough with 3m people and just seven health boards to get everybody together in the same room and have those sorts of discussions,” he explains.

GP record and My Health Online

NWIS put the GP record at the heart of its last IT strategy, and says it will continue to be at the heart of its latest document, which is set to be published imminently.

It argues that the quality of the out-of-hours services in Wales has improved markedly, thanks to the access now provided to a patient’s GP-held information through the Individual Health Record summary.

Meanwhile, patients have been given improved access to GP services through My Health Online, which – unlike England’s failed HealthSpace project – focused from the outset on transactional services, such as appointment booking and repeat prescriptions, rather than on records.

To date, the bilingual service has 10,000 users, with 107 out of the 490 GP practices signed up to the initiative. Extended capacity is set to be switched on shortly and NWIS believes that it shall be in a position to support all GP practices.

Murphy says: “We wanted to give patients the ability to interact with the GP system, so what we have set out about doing in the first phase – which is now available – is to provide access for patients to book their appointments and order their prescriptions online, and to allow this across all GP systems with one front end.”

It is hoped the system will eventually incorporate ‘messaging’ between a patient and a GP. “The idea is to move onto messaging and access to the record when everyone has the necessary confidence.

“This is often our way. We take something that is a bite-sized chunk that people can trust, and we show it works, and that gives people the confidence to take the next step. If you have 15 different hospitals, with 15 different systems, you have to gradually get them to where you want them. You have to be careful and that’s all based on trust.”

Portal success

Murphy also argues that the success of system implementations in Wales owes plenty to their in-house development.

The Welsh Clinical Portal, which is in use in secondary care, provides clinicians with a ‘single view’ of information from the different systems in use in Welsh hospitals. This includes information from the various patient administration systems in use (Myrddin and two iSoft PASs) and pathology.

NWIS decided to develop the portal because many clinicians encountered different systems while travelling around Wales for work. By developing a single front-end for employees, it was hoped that patient safety and experience would improve.

The portal incorporates an enterprise master patient index from IBM and an administrative register, which NWIS believes delivers a “gold standard” for the identification of patients in the system. Further, clinical functionality is under development.

“In testing at the moment are alerts and notifications. When you get a test back, the system flags it up to clinicians, meaning there is an audit trail that clinicians cannot miss,” Murphy explains.

“Around 50% of litigation in the UK is down to doing a test and not looking at. We’ve done beta testing for this development, which should live shortly, and that will be a huge safety benefit.”

Murphy adds that ordering for radiology is “about a month off” and that a medicines list is about to be tested in the wards in Cardiff and Vale University Health Board, which will be implemented for “pharmacy orders and discharge summaries.”

Teething problems

However, in-house systems have not been immune from problems. As reported by EHI in June, Aneurin Bevan Health Board’s installation of the national PAS, Myrddin, caused significant disruption to the board’s day-to-day running, particularly in outpatient services.

Murphy and his NWIS colleagues are adamant that these teething problems have been solved by engaging with clinicians and the IT team at the board.

“We have taken the Myrddin PAS and we have been spreading that across the country. We have worked through the problems and it was simply a case of miscommunication. I think it is fair to say that there is now no Myrddin noise from Aneurin Bevan,” adds Murphy.

National contracts

NWIS is also not frightened of entering the commercial market if it believes a product can satisfy its requirements, and a number of such procurements are currently taking place.

NHS Wales recently embarked on a replacement of the country’s laboratory systems, in a £12.1m deal with InterSytems. The organisation also signed a £20m PACS contract with Fujifilm in April, the first deployment under which has just gone-live at Betsi Cadwaladr University Health Board.

Another ambitious project instigated by NWIS will see the procurement of a document repository system that will act as the “legal record” for a particular patient, presented in a similar fashion to traditional case notes.

“One of the issues that we have recognised is that the idea you can have a fully structured record for everything doesn’t work.

“What we do know is that humans communicate through documents, notes and other messages we send to each other, so it would be very helpful to organise them in a modern document repository,” says Murphy.

The specification for such a system has already been devised and the tendering process is set to start shortly.

“In one sense this is a very simple concept, but in another it’s very complex as it is using technology that has only become available recently.

“Plus, of course, you have things that can sit on top of this and search it like Google. You can get a lot of things out of it which five years ago you couldn’t.”

New IT strategy ahead

The upcoming IT strategy is set to build on the foundation of what Murphy describes as the “Welsh platform”; adding functionality to project such as the clinical portal using a best of breed approach that NWIS calls “AP Cymru.”

In doing so, however, it must take account of the financial pressures that have hit the NHS in Wales, forcing it to take a radically different approach to healthcare, focused on smaller hospitals and more care outside them.

Murphy believes NWIS can handle these issues with the strategy it has adopted. “Like everyone else, we are taking hits; which is understandable giving the state of the economy. But with the strategy we have got, it’s possible to continue progress, as a lot of the stuff we actually own.

“We may also be in a better place because of the migration strategy, as it is possible to take things on slowly rather than going for rip and replace.

“All we are doing is recycling the revenue we have got when there is every little capital around. We are taking a collaborative, migratory approach and I think a lot of the companies are recognising that this is how it’s going to be from now on.

“We are optimistic. Things are going well; the stuff is very solid, well tested and we are not trying to take over the world – but we are trying to collaborate to make a world class system.”