7: IT INFRASTRUCTURE
7.1 The Scottish Government's eHealth Strategy covers the period 2008-11. It outlines how eHealth can support the overall goals for NHSScotland highlighted in Better Health, Better Care. To date, Scotland has taken an incremental and pragmatic approach to developing eHealth solutions, and this will continue. However, the need for national coordination and collaboration at all levels is fully recognised, alongside the need for space for local flexibility and innovation. The developments for heart disease and stroke outlined below are entirely consistent with, and will support, the national direction of travel for eHealth.
Heart Disease Developments
7.2 Greater focus is needed by NHSScotland on the collection and collation of information related to the care of patients with cardiac conditions across Scotland. Emphasis should be placed on the use of information to improve patient care. Information should also be made available to key stakeholders at planning, managerial and clinical levels within the NHS to support service development.
7.3 A culture of data collection and reporting has been developed and strongly encouraged throughout secondary care, using information from established databases for cardiac surgery, PCI and the more recently implemented acute coronary syndrome register ( SCI- CHDACS). Clinicians and other CHD staff have a responsibility to support data collection at local, NHS Board, regional and national levels. Local data collection should be co-ordinated by Managed Clinical Networks. While specific CHD data officers have been key to this process, clinicians and other CHD staff have been directly involved in agreeing quarterly reports of data which reflect activity, and more importantly the quality of care being delivered in each centre. Plans to improve the accuracy and consistency of cardiac data recorded using the SMR01 system are being linked to this process.
7.4 A directly relevant project, the NHSQISCHD Improvement Management Programme (see paragraph 6.14) addresses the challenge of Guideline implementation and the establishment of processes which can assess quality of clinical care on an ongoing basis. This new approach to improving patient care, aligned with the Patient Safety Programme and Waiting Times standards, provides a sound basis for developing local templates.
7.5 A review in November 2006 of the role of current staff recognised that they needed to have wider involvement in CHD data collection than revascularisation audits. In January 2008, the Data and IT Sub-Group agreed that a wider programme of audit was required which provided measures of quality of care while also providing ongoing support for waiting times and quantitative data for service planning. In the light of these developments, NHS Boards, through their cardiac MCNs, should take the opportunity to clarify future staffing and funding arrangements for cardiac data collection within their local areas, in order to realign the focus of data collection towards the support for NHSQIS, ISD and local reporting mechanisms, rather than continuing the inputting of extensive data to registers.
7.6 In undertaking this exercise, NHS Boards are encouraged to make best use of the time-limited funds that have been made available by the Scottish Government, and NHSQIS, to support the move towards a new model for data collection in Scotland.
7.7MCNs should work with local colleagues who have responsibility for the implementation of core work programmes such as 18 weeks and the Scottish Patient Safety Programme to ensure that relevant information relating to patient care for cardiac conditions is being captured and utilised. There is now a growing consensus as to the core information that is required to monitor patient care. The new model proposes focussing on the collection of a smaller number of key indicators to assess the overall performance of cardiac services. At a national level, work is required to develop an overall reporting framework that monitors clinical activity and patient care. The framework should build on HEAT principles summarising indicators from existing data sources and QIS standards. Further work is required to identify potential gaps in data collection which may need to be addressed.
NHS Boards, through their cardiac MCNs, should ensure that information systems are in place in order to meet the requirements of NHSQIS and ISD for the reporting of information relevant to cardiac care drawn from a range of core indicators that will be determined by May 2010.
NHSQIS, ISD and other relevant bodies, including the SAS, are required to establish mechanisms for reporting and publishing these data.
National Clinical Datasets Development Programme
7.8 A large body of work has been completed through the National Clinical Datasets Development Programme ( NCDDP), hosted by the Information and Statistics Division ( ISD), in developing and agreeing a comprehensive dictionary of data items for patients with CHD. Datasets are now available for heart failure, pacing and electrophysiology, cardiac rehabilitation, core cardiac information and acute coronary syndromes, and are currently being developed for chest pain clinics, cardiac catheterisation/angioplasty and cardiac surgery. Since Familial Hypercholesterolaemia is included in the NHSQIS clinical standards for CHD, the NCDDP should be extended to include FH.
The cardiac MCNs, and staff collecting information, should ensure that data definitions meet NCDDP criteria.
The NCDDP should be extended to include familial hypercholesterolaemia.
7.9 The National Advisory Committee's Data and IT Sub-Group has developed a high level specification document for an electronic patient record which aligns with the national eHealth agenda. This aims to build, in a modular fashion, a comprehensive clinical electronic record for patients with heart disease.
7.10 A range of IT solutions which allow routine, prospective clinically relevant data to be collected and reported are required as a matter of some urgency. An eCardiology Strategic Group should be established through the merger of the eHealth Implementation Group and the SCI- CHDACS Steering Group. It will be charged with developing an eCardiology action plan for consideration by the eHealth Programme Board. Proposed developments must be aligned to the national priorities for data collection. Particular focus will therefore be placed on finding solutions to support the monitoring of NHSQIS clinical standards, the Scottish Patient Safety Programme and audit indicators, routine reporting by ISD, together with the ability to exploit future tracking systems for monitoring referral to treatment times for cardiac patients. Given this set of priorities, serious scrutiny needs to be given to the range of data collection systems currently in operation, with a view to determining whether these are fit for purpose.
The Scottish Government will establish an eCardiology Strategic Group to develop an action plan for consideration by the eHealth Programme Board by end December 2009.
SCI- CHD Acute Coronary Syndrome ( ACS)
7.11SCI- CHDACS is an audit system with substantial clinical functionality that enables web-based collection of NCDDP compliant data on the management of ACS patients. The first version was released in January 2006 and the system is now switched on in 28 hospitals, with another four currently working through the implementation process, including the Golden Jubilee National Hospital and the hospitals in NHS Lanarkshire.
7.12 Current functionality includes:
- NCDDPACS dataset: the system utilises and has extended the nationally agreed NCDDPACS dataset, ensuring that consistency of data is maintained across NHSScotland;
- Link to National CHI: this ensures that all patient data has a validated CHI number attached to it where possible;
- Production of discharge letters: data collected throughout the patient's admission are compiled to produce pdf Immediate and Final discharge letters. The letters are compliant with the relevant SIGN Guideline and contain the fields required to send discharge letters through SCI Gateway. Robust sign-off mechanisms for junior doctors, consultants and pharmacists have been incorporated, and a support mechanism for secretaries to manage the printing and filing of letters is also available. For the moment, a hard copy of the discharge letter will be sent to the patient's GP, but in due course will be transmitted through SCI Gateway.
- National STEMI Standards: the ability to instantly produce predefined reports for submission of the Scottish Quarterly STEMI standards, subsequently allowing benchmarking across NHSScotland;
- MINAP: in conjunction with ISD, work is in hand to transfer data from SCI- CHD to MINAP, to allow UK benchmarking. This link has been successfully piloted and live data will be transferred in the near future.
- National Networking Model: this incorporates a new security model to allow the viewing of records between hospitals across NHSScotland. Links between hospitals within the same region can be activated to freely share episodes on a view-only basis, e.g. Raigmore Hospital can activate a link with Western Isles Hospital. The regional model has been extended for those major receiving/interventional centres to allow links across NHSScotland rather than just within regions. Hospitals in which links have not been activated, or are outwith the region, can still share records, but this is done using a 'break glass' function where a reason for accessing the record must be given.
Demonstrations of the functionality of the system have been given to the three Cardiology Regional Planning Groups. The Scottish Government, the SCI- CHDACS chair and the NHSQIS Clinical Advisor are working closely with NHS Boards' Caldicott Guardians to ensure data transfers meet required information governance standards.
- SIGN Guidelines integration: elements of SIGN Guideline 93 have been incorporated into SCI- CHDACS to allow clinicians easy access to relevant guidance.
- Risk Score Calculation: risk calculators have been incorporated into the system and will be used to select patients for urgent in-patient transfer to regional centres for investigation and/or intervention in accordance with NHSQIS standards.
7.13 Over the coming year, SCI- CHD will build on the National Networking Model, moving away from the ACS orientation that the system has followed up until now. It will increasingly look at bringing together data on cardiology patients from varied sources into a central location through improving clinical care and improving speed of access to data by clinicians.
The eCardiology Strategic Group should look at extension of this CHD information gathering to primary care.
7.14 Discussions are ongoing with NHSQIS to fully embed the production of the NHSQISCHD standards into SCI- CHDACS. SCI- CHDACS will develop a multi-functional tool, allowing use as:
- an ACS registry;
- a tool to collect the NHSQIS sample audit data;
- a tool to monitor the Scottish Patient Safety Programme performance measures for ACS; and
- a clinical system embedded in the clinical environment, producing 'real time' data.
The need for duplicate data entry and collection will be minimised, and the system used to deliver regular reports for quality improvement.
NHS Boards, in conjunction with their cardiac MCNs, need to establish mechanisms to collect the NCDDPACS data set through SCI- CHDACS (or a compliant alternative system) by March 2010.
The eCardiology Strategic Group, working closely with representatives from the Scottish Government, will ensure development priorities are delivered within the agreed funding arrangements and timetable.
7.15 The Wellcome Trust has recently funded (£3.6m) the Scottish Health Informatics Programme ( SHIP), a Scotland-wide platform to enhance the use of patient records for research. The programme builds on ISD's ongoing development of a secondary uses service for NHSScotland to establish a research portal to test new ways of linking health service records with external research datasets.
Links to Scottish Ambulance Service
7.16SCI- CHDACS will continue to work with the Scottish Ambulance Service ( SAS) on ways of transferring data from the central SAS system to SCI- CHD. These data are key to the optimal reperfusion service. Currently the SAS does not record the patient's CHI number against the ambulance record, which eliminates the possibility of linking records within SCI- CHD. Work is taking place within the SAS to rectify this in the coming year.
The Scottish Ambulance Service, working with other national bodies, should continue to explore mechanisms to link their databases with SCI- CHD, to improve national data collection on the delivery of optimal reperfusion services.
7.17 As part of the eHealth strategy, there will be a national contractual framework in the near future for Board procurement of GPIT systems which will require such systems to meet certain criteria. To increase usage of ASSIGN (see paragraphs 3.28-3.29), functionality to embed the tool in the clinical system will be considered for inclusion as a highly desirable feature in this contractual framework, which is currently being developed by a consortium of NHS Boards.
7.18 Several strands of work have been proceeding in the area of stroke eHealth, which have already brought minor improvements in patient care but which promise to yield important benefits over the next five years.
7.19 As in the case of heart disease, the National Clinical Dataset Development Programme ( NCDDP) coordinated by ISD, has developed agreed clinical terms which can be used in Clinical Information Systems. The clinical stroke community has worked with the NCDDP to produce several datasets including those relating to inpatient care, outpatient care, nursing and allied health professionals ( AHPs). This work is an essential step in introducing electronic patient records ( EPR) to stroke services.
7.20 The Scottish Stroke Care Audit was developed under the auspices of NHSQIS. Currently it comprises a separate audit based in each NHS Board area which uses comparable methods and software to collect, store and analyse a standard dataset which reflects the performance of services' delivery of evidence-based stroke care in Scotland. Each MCN employs audit coordinators who extract audit data from clinical casenotes, enter it into their database and analyse it. Each year the data from these audits are pooled to provide a National Report which is the main tool for monitoring progress against the NHSQIS standards for stroke service, the targets set in the Strategy and also MCNs' own targets for service improvement. The audit has demonstrated improvements across many aspects of stroke services, but there is still a long way to go.
7.21 The stroke audit is now being integrated within ISD as part of the coordination of all National Audits. Data which reflect quality of care will be transferred from electronic patient records ( EPRs) to an audit system which will increase both the efficiency and accuracy of data collection. Increasingly, audit data will reflect current, rather than past, performance, and will help to identify service areas in need of improvement. A central database is now being developed at ISD which will allow integration with other datasets, such as SMR1 and General Registers of Scotland.
7.22 Several stroke MCNs have developed and implemented EPRs to support their stroke services.
EPR use in local stroke services
The stroke unit in Ninewells has introduced an electronic patient record which allows the multidisciplinary team to record their work and to produce daily job lists for team members, and immediate and final discharge summaries. Team members enter information on laptops with wireless connections to hospital intranet.
In the neurovascular clinic at the Western General Hospital, doctors and nurses enter patients' history and examination directly into a purpose built web-based system. This allows the doctor to generate a letter to the patients' general practitioner during the consultation. The patient can take the letter to the GP the same day which ensures that they are started on appropriate treatment as early as possible. The system also produces typed requests for investigations and tailored information packs for patients and has markedly reduced the time spent dictating letters and typing them.
7.23 Although these local EPR systems work well in the services which developed them, there are significant hurdles to rolling them out across the country, including the fact that they do not currently communicate with each other, or other local IT systems such as laboratories and radiology. The Scottish Government has therefore provided project funding to:
- amalgamate the work already done on EPR in various NHS Boards, in particular Glasgow, Tayside and Lanarkshire as well as GCS modules in Lothian;
- build a detailed specification for a national generic EPR for stroke; and
- liaise with the Scottish Government eHealth Team to agree the way forward nationally.
The detailed EPR specification is being developed in NHS Lothian using TRAK software. It is hoped that the specification will provide NHS Boards with the necessary support to develop a national EPR for stroke within their individual Patient Management Systems.
7.24 The Scottish Government initiative of rolling out the national Picture Archiving and Communications Systems ( PACS) system to all hospitals in Scotland is directly relevant to stroke patients. Plain X-rays and scans are now captured digitally and can be stored on computers, allowing doctors from across Scotland to see images, even if these were taken at another hospital.
7.25 The roll-out of the PACS system will bring particular benefits in the case of stroke patients, where doctors are very reliant on brain scans to make an accurate diagnosis. The system will enable clinicians to get a specialist opinion on the scan very rapidly, from another expert working in a different hospital, with obvious clinical benefits.
7.26 Telemedicine is also being used in a number of settings across Scotland to allow stroke patients to receive earlier and therefore more effective treatment with thrombolysis at their local hospital, even when a local stroke specialist is not available (see Chapter 5).