Simon is an IT manager at a GP surgery in the West Midlands. He has been in the IT industry for more than 21 years, first as a programmer, then as a computer analyst/consultant/specialist. Simon has worked in general practice for the last five years. His present position involves dealing with the local PCT in all matters relating to Connecting for Health, as well as the normal day-to-day operation of the computers and network within the surgery
Two parts of the new Information Management and Technology (IM&T) directed enhanced service (DES) have been designed to make life easier for general practice, but is this really the case?
Component 3, Electronic Prescribing, will be introduced in two releases and should be completed by the end of 2007. Release 1 is currently being rolled out by the various clinical system software suppliers. Once the software is installed, your only other requirement is a laser printer capable of printing at 600dpi. This may not be your normal setting, so you will need to check.
Prescriptions will be produced as normal, except that a barcode will be printed on the front. Pharmacies are currently installing equipment to read these barcodes. With Release 1, you will only be able to print four items on a prescription. You must use Release 1 to comply with the requirements of the DES. Already, 5% of current prescriptions are being issued using Release 1, which amounts to more than seven million prescriptions.(1)
Release 2 is far more interesting, and should show definite benefits to the surgery. This will allow for the electronic generation, transmission and receipt of prescriptions from the surgery to the pharmacist. The community pharmacists are currently being issued with smartcards.
The aim is to reduce the amount of time surgeries spend dealing with repeat prescriptions. It is estimated that 70% of all prescriptions issued are repeats.(2) Patients will need to register with the surgery and up to three pharmacies of their choice. If a patient is on long-term repeats, their doctor will be able to issue six months worth of prescriptions electronically to the relevant pharmacist.
This means that the patient will not need to contact the surgery for six months in relation to that prescription. This should free up administration staff from the monthly round of reissuing and reprinting repeat prescriptions, and it means doctors' time will be saved by not having to check and sign the repeats.
The patient will contact the pharmacist every month to get the issue he/she requires of his/her medicine. This benefits the patient, as he/she does not have to keep contacting the surgery. The doctor still has full control of the prescription. If it needs to be cancelled, this can be done electronically as well.
The system will require electronic signatures. These are achieved using the NHS smartcard – the same as is currently used for Choose and Book. If you do not already have these issued for all your staff members who use computers then you will need to contact your primary care trust (PCT) as soon as possible, so they can get them issued.
The NHS has currently issued more than 300,000 smartcards to NHS staff,(3) and 85% of community pharmacists are registered for their smartcard. Also, 98% of surgeries have a broadband N3 connection, and 2,116 surgeries are already enabled and ready for the Electronic Transmission of Prescriptions (ETP) programme.(1)
Centralised data storage
Component 4, Hosted Solutions, is a more interesting issue. Opinion seems divided as to whether this is a good thing or not. The aim is for your clinical data to be stored at a remote, centralised location. This could be your local PCT data centre, the local cluster data centre or even your clinical system providers' remote data centre. You would not hold the patient's electronic medical record at your surgery.
The main benefits of this for the surgery are that you do not have to worry about data security or performing backups. You would access the patient's details via your N3 connection. You would also not need to worry about future server upgrades or running out of hard-disk space to store all your records and attachments. Your host will maintain the system, perform regular data backups and ensure that you do not run out of space. You would access the data via your secure N3 connection.
The key question is: is this link going to be fast enough for you to operate effectively? If you use your smartcard at the moment, using the EMIS Primary Care System (PCS), for example, every time you select a patient's medical record the system automatically links to the spine to check demographic data.
On our system, this can take anything up to 15 seconds. If you try to use the patient record before the demographic data is received, it can cause problems with system stability. At the moment, only a few staff members use their smartcards. How will system performance be affected when everyone is using smartcards?
Another major concern is: what happens if there is a system failure? A power failure, or other catastrophic failure at the data centre, would mean all the surgeries using that centre would be out of action! Does your provider have a "mirrored system" located elsewhere? (ie, an exact copy of the live system in another location – so that in the event of failure of your primary system, you can be switched to the mirrored system automatically). If not, do they have the resources in place to handle communications with large numbers of users, to inform surgeries exactly what is happening?
If GPs are sitting in their surgeries and their system suddenly stops working, you need to be able to contact the data centre straight away to see if the problem is there or if you have a more localised problem. Unfortunately, there are likely to be 60–70 other surgeries also trying to phone the data centre at the same time to get an answer.
Confidentiality is another concern about centralised data storage. Connecting for Health assures everyone that only suitable, authorised staff will be able to access the data. This will be done by using smartcards with a Role-Based Access Control (RBAC) system. Legitimate relationships will be set up, allowing only those people who have a right to the information to access it. This will include anyone with a legitimate need to access a patient's medical history, including dentists, opticians, chiropodists, etc.
If anyone tries to obtain information to which they have no legitimate claim, an alert will be given to the system administrator. A centralised system could also allow PCT staff to obtain relevant information without having to visit the relevant surgery. This could help monitor performance and help identify problem areas in specific surgeries before they exacerbate.
Our PCT would like to get all local surgeries onto a single centralised system if possible. Lorenzo, from Isoft, is being developed with this in mind. EMIS, which has roughly 60% of the GP software market share,(1) is also developing its own hosted solution, called EMISWeb. In Practice Systems, whose Vision software is used by 20% of the GP market,(1) is also offering a hosted solution with its Enterprise edition.
The EMIS solution offers an alternative method of using a hosted system. The main aim of a hosted system is to store all clinical data in a centralised location. Your clinical system is linked live to this remote storage facility, and no data is stored locally. However, while the EMIS solution offers online remote storage just like Lorenzo, it also enables you to back up your live data overnight to a local server in your surgery.
This means that if the centralised location has a problem, or your link fails, you would be able to switch to the locally stored backup, which at most is only 24 hours out-of-date. This means your GPs would still have access to patient medical records, and could continue to see patients secure in the knowledge that the patients' previous medical history information is available at their fingertips.
GP System of Choice
Unfortunately, at this point in time I don't think any system can offer what is required. If you feel that this is not the solution for your surgery, you do still have a choice, thanks to GP System of Choice (GPSoC), which is due to start in April 2007.
While Connecting for Health is starting to think that it is unacceptable for patient data to be stored on a local system and that a hosted solution is required, they do recognise GPs' choice of system under the contract, and currently the option remains to keep your own server in the surgery.
Funding under GPSoC will only be available to upgrade your existing system to a local service provider (LSP) solution or for upgrades to your current system. To achieve Compliance Level 4 (there are six Compliance Levels within the GPSoC) you are required to have a hosted system. It is expected that, as Level 4 systems become available, surgeries will upgrade or transfer to a suitable option.
Any supplier of a hosted system must demonstrate that they can maintain continuity of service in the event of a disaster. This will include explaining where surgery data is stored, and what provisions have been made for recovery if required. You will only be paid for this part of the IM&T DES after you have moved to a hosted solution. Because of this, claiming payment for Component 4 is allowed up until 31 March 2008.
Conclusion – is resistance futile?
It would appear that the ETP programme will save administration time in general practice, as well as offering patients a more convenient service. Hosted solutions will really be a matter of preference, once it can be demonstrated that hosted systems are fast and robust enough to withstand the pace of modern general practice. However, if you opt for the hosted solution you will no longer have the responsibility of maintaining your patient medical records' back-up and data storage space.
As I heard someone say the other day: "I would not like to think that all my bank account details were held only in the local branch." Ultimately, the choice may be taken away from the surgery. If the software suppliers decide to develop only hosted solutions, you will have no choice but to comply!