Everything you wanted to know about GP Consortia IT

I organised what I think was the first national GP computing exhibition in 1981 for the GP Computer Suppliers Association  (now part of Intellect) it was a sell out and I have been trying to organise another sell out event  without success ever since. However, with the BCS Primary Health Info Conference I am helping to organise at present I think I might have finally achieved my ambition www.primaryhealthinfo.org

This is particularly satisfying as it was the PHCSG that picked up the original GPCSA exhibition and merged it with their conference to create a series of conferences over the past 30 years of  which Primary Health Info is the most recent incarnation.

PHCSG conferences have a history of responding to the current zeitgeist in primary care IT and this year’s event looks like it will do it again this time around GP Consortia.

It is wildly recognised that better use of information and information and communications technology is going to be central if we are to rise to the challenges facing the NHS (and indeed health care systems across the developed world). In particular making the Governments plans, centred around GP Consortia, work against the background of austerity and deficit reduction is going to require the innovative use of information and IT without the luxury of being able to invest more than a modest amount in new infrastructure and systems.

The process is a bit like this.

Coming to Primary Health Info is sadly not going to answer all of your questions but it will enable you to answer many of them and help you understand that for many others nobody knows the answers and indeed that we haven’t even worked out what all the questions should be yet.

However, Primary Care Info looks like being the place where we might make progress. We have speakers, exhibitors and delegates who are working on the issues now, both in the ivory towers of Government and Informatics, but also at the grass roots with the PBI in general practice. Some of these know some answers, some think they do, while others don’t have a clue and may or may not be honest enough to admit it. There are going to be lots of opportunities to ask questions and network and greater apparent clarity may emerge in the conference bar (although experience tells me that we may not remember of brilliant late night insights in the morning).

We are also trying an experiment and running a technical steam alongside the main conference stream. This stream has speakers who are experts in the important but arcane aspects of health informatics SNOMED, HL7, CDA, XDS, FAD, PETs. This stream is intended to attract a different set of delegates mainly from the vendor community who have to know not just what these abbreviations stand for (a beer on me at the conference for the first 10 people to email me with the correct meaning of all of the above) but how to make them work in practice. We are doing this partly to attract more delegates but also to encourage a dialogue between the techies, the policy people and frontline NHS people as we believe it is only by each of these groups understanding a bit more of the others worlds that we are going to crack the challenges we face. We hope to do these through the plenary sessions, which run across both streams,  by building contacts through informal networking an by encouraging delegates to wander in to the odd session in the stream other than that which would be there natural home.

Hopefully by the end of the event we will all know a bit more, have a clearer idea of those things that still need to be resolved, made some new relationships to help us work together and probably most importantly help to influence the agenda with the powers that be.

We have a number of half-price places for those who work in the NHS and NHS GP practices, but these are going fast, so book now www.primaryhealthinfo.org

I look forward to seeing as many of you as possible at the event and would encourage you to tell your colleagues to come to, but secure your own place first.

King’s Fund Inquiry

The King’s Fund Report on their inquiry into the quality of general practice “Improving the quality of care in general practice”  www.kingsfund.org.uk/current_projects/gp_inquiry is worth a read by anybody interested in UK healthcare. Even if it does manage to get the date of foundation of the RCGP wrong by 20 years (page 14) – it was 1952 and the context shows the error is not just a typo. However, I digress as what I want to pickup is just one statement from the reports “Key Messages”:

“Technology is available that could transform the way patients interact with general

practice. However, general practice has been slow to adopt it.”

I don’t believe this is really true and it is certainly not fair.

It is true that general practice has not adopted some of the available technology to the extent and on the scale that might have been possible in the leadership of the NHS and to a lesser extent the leadership of the profession had created an environment where such adoption was encouraged and enabled. However, general practice has pioneered many of the possible uses of technology, often with opposition from or at best indifference from the powers that be.

GP Computerisation leads the world and remains one of the few examples of widespread use of IT at the point of care. This have been the norm in nearly all practice for over 10 years with the majority operating paperlite (i.e. not pulling paper records in the consultation) this contrasts with most other care-settings and most other countries where the clinical use of computers at the point of care remains a minority sport. If we look at other areas GPs have led the way in so many. GP practices were the first NHS organisations to have web sites and GPs with support from systems suppliers, have pioneered online appointment booking, repeat script requesting, online consultations and online access to patient records.  While the rest of the NHS debated whether these things were either useful or practical pioneering GP just got on with it and proved that they were both. For the King’ Fund Inquiry to point the finger a GPs for the failure of these things being more widely implemented is unfair – The problem lies elsewhere;  where those petrified by the possible impact of disruptive technologies, those seeking evidence where not can exist, those tied up in arcane governance concerns and those hog-tied by inappropriate IT contracts.

GP lost control of their IT with the 2004 GP Contract and this has stifled the ability of GP and their supplier to innovate and then drive implementation of successful implementation. Lets hope that GP Consortia can put the control of GP IT back in GPs hands and that we see a resurgence of the grass-roots innovation that got GP IT to it current leading global position.

EPS and the Electronic Transfer of Prescriptions

I first worked on the forerunner of what we now call EPS (the Electronic Prescription Service) in 1986, when I wrote an evaluation of a project to using a memory card to transfer prescriptions from GP practices to pharmacy for the then DHSS. However, even this was not quite the beginning of the EPS story as there had been some other projects earlier in the 1980s.

By 1986 most community pharmacies were already computerised (driven by a requirement for typewritten medicine labels and the widespread use of online order entry by the pharmaceutical wholesalers), GP computing was beginning to take off (although still at only about 5% penetration) the Prescription Pricing Authority was computerised and it already seemed obvious that it would be a good idea if prescriptions could flow electronically.

By the early 1990s GP computing had boomed and we had reached the point where 80% of prescriptions reaching community pharmacy were computer generated. With 600 million+ items prescribed annually it seemed an obvious “no-brainer” to try and move from a situation where much of the same information was typed and re-typed in to three different computer systems. The problem also didn’t look too difficult. Prescriptions consist of a small amount of fairly structured data that it would be simple to convert into a computable form that would not make excessive demands on the bandwidth or storage capacity of the then available technologies.

Numerous pilots ensued. These fell into two groups. Firstly those using some form of machine readable token, still physically transported from GP to pharmacy (this included chip cards, smart cards, magnetic stripes, 2D bar codes and optical cards). Secondly, there were those using online communication (either point-point between GP and pharmacy or via some form of email or relay service) There were a couple of attempts to launch a commercial service and I was involved in a project that tried to set up a joint industry owned service (it would have been like BACS but for prescriptions). These projects proved the concept and addressed many of the practical and professional issue involved and with the birth of the NPfIT it picked up the EPS baton in England to take forward what had been learned in this early work.

Image of Care Card
Care Card from 1987 Exmouth Smart Card Project

Twenty Five years after the first work, we have fairly comprehensive infrastructure in place in GP practices and community pharmacies in England and most have software to support EPS release 1, with about a third of prescriptions produced by GPs flowing to the EPS service. However, NHS Prescriptions (the successor organisation to the PPA) is still processing paper prescriptions (although in now uses scanning and OCR rather than manual data entry) and less than 2% of prescriptions are processed using EPS in pharmacies.

Why have we made so little progress in a quarter of a century?

There are a number of reasons, but paramount has been the determination by Government (driven by the pharmacy lobby) that EPS should not be allowed to become a disruptive technology, that could radically alter the medicines supply chain and potential destabilise community pharmacy. This in my view has been a critical error which has denied potentially significant benefits to patients, the NHS and those willing to take advantage of the commercial opportunities to drive efficiency and quality in the supply chain.

However, in the current economic climate

Government can no longer afford to take a protectionist stance and EPS release 2 provides the opportunity to improve both quality and efficiency, mainly by improving the truly dreadful process patients have to follow to get regular medication.

Patient concordance with medication is really poor (see my earlier blog post http://bit.ly/hkdyu8 ) and in the medium term this increases costs, morbidity and reduces patient’s quality of life. EPS can make repeat prescribing more efficient and convenient but more importantly makes repeat dispensing (where the pharmacy takes over responsibility for refills) a much more practical option than in its current paper based form (indeed with EPS 2 repeat dispensing should completely replace repeat prescribing) While supply issues are far from the whole story with regard to concordance they are a big factor and a switch to pharmacy managed repeat dispensing enabled by EPS should have a significant positive impact, not to mention improved patient convenience and efficiency gains, particularly for GP practices.

EPS 2 has only just started to roll-out and achieving the benefits it promises requires action in a number of areas.

  • An acceleration of the role-out so that the benefits EPS2 offers “as is” can be realised. We should stop worrying about the commercial impact on community pharmacy and abandon the requirement for a Secretary of State’s Direction for local implementation.
  • We need to address those issues that mean not all prescriptions can use EPS.
  • We need to address the legitimate concerns of pharmacy with regard to business continuity in an EPS environment.
  • We need to address aspects of EPS that have a negative impact on efficiency in community pharmacy and ensure that future releases deliver the key benefits that pharmacy wants (including full automation of the application of exemptions and remissions from prescription charges and automated line-item reconciliation between dispensing and payment).

It’s been a long time in coming, we are nearly there and it would be good to see EPS becoming ubiquitous before I retire.

Life without a Moblie Phone

Both my adult children have recently had their phones stolen. Both were bereft.

This lead to the following email to my son with some reflections on life without a mobile phone.

Hi Silas,

How are you finding life without a phone?

Interesting to reflect on this. You were born in to a world where very few had mobile communications, but I had a car phone by the time were you were two and you had your own mobile at 14, so pretty much all of your independent life you have had a mobile phone. You are of the first generation in this position and it has certainly changed the world.

As a teenager most of my friends had a phone at home although there was a significant minority without one (we didn’t have one until I was 12, and your mother had long left home before her parents installed one) I spent most of my time at university and in the few years after in shared houses with no phone.

Mobile communications was for a few restricted uses and much restrained by cost, the technology, available radio spectrum and regulation. The only way for an individual citizen to get legal mobile communication was as an amateur radio enthusiast and this required a licence that necessitated passing technical and Morse code tests, but did give you access to SW radio which with the aid of a big enough aerial and a shed full of kit allowed global communication (SW will propagate in the ionosphere, so with the right conditions you could get voice communications with Australia).

Radio telephones using VHF were restricted with civilian licences only available to the likes of taxi firms, private security operators and GPs These things operated with a base station with a big aerial and could manage a few 10’s of Km range, but only very short distances mobile-mobile without relay through the base station which required manual patching by the base station operator.

One of first publically available national radio telephone service came with deregulation in the early 1980’s which allowed Securicor to open up their network of base stations (set up to communicate with their armoured delivery vehicles) to anyone who could afford it. This service still requires manual intervention to patch you through to another user and the operator could also patch you through to the POTS and would do things like make a restaurant reservation for you. The kit was such that it really needed to be installed in a car, but it was possible to get a luggable unit. However, this technology was very expensive and really only affordable by rich individuals or businesses with imperative need for mobile communication. I worked with someone who had a Securicor phone and I made my first mobile call on it in 1983.Shortly after Securicor partnered with BT to set up the Cellnet mobile network.

The introduction of cellular phones in the mid-1980’s started the mobile revolution as it massively increased capacity and provided automated switching between mobiles and with the POTS. The first phones were luggable and really needed a car installation, but I used one of these on the train for the first time in 1987. Also at about this time the first phone designed as a hand portable appeared this was the size of a brick with a 6 inch aerial (it battery life was also about that of a brick) This was a great favourite with City Boys and is probably the most iconic artefact of Thatcher’s “loads-a-money” deregulated Britain http://bit.ly/cpusa1

With my car phone in 1987 I was amongst the first to have a mobile It cost over £1,500. However over the next 10 years prices fell, the technology improved (and importantly went digital allowing SMS messages), network coverage and devices improved and by the mid 90’s mobile phones had become affordable by the masses.

Before than life was different. Meeting up with people required that you knew where to find them (people were much more tied to home or office) or prior arrangement (mainly made by fixed line phone.)When you were out and about it was difficult to communicate and the only way it could be done was with complex arrangements using call boxes and other fixed line phones to relay messages. There was much hanging about and prematurely terminated activities when pre-arranged rendezvous got out of step with changing circumstances and you never knew if you had just been stood up, forgotten or if some disaster had befallen the person you were supposed to be meeting.

In your world all of this has changed and it’s a double edge sword. On one side you get the peace of mind of easy communication and you are freed from the need to tie yourself to particular locations and pre-arranged plans, while on the other side you are expected to be always available, always contactable.

All in all the connected world seems a better one to me, but it is interesting to discover what we do when these things breakdown, particularly those with no experience of different ways.


English GP Systems Market

I’ve been looking at some statistics on the GP market in England which may be of interest.

Recent years have seen a considerable consolidation in the market and although there were never the number of suppliers that some of the literature suggests (The peak was probably about 40 suppliers who had sold at least one system beyond its development sites and there were never more about a dozen suppliers with more that 100 sites) However, we are now down to four significant suppliers , one small company, with a stable user base of about 160 concentrated in Cornwall and the SW and a few remnants.

We have also seen a move form practice based to hosted systems with all of the major suppliers except iSoft having a significant number of hosted systems, although the majority of systems remain practice based. This is likely to change, particularly as EMIS web starts to rollout and the only question is how long it will take for most GP practices to move to hosted systems. The hosting model is the traditional data centre one and we have yet to see GP systems appear in the cloud (but it can only be a matter of time)

National market share does not apply once you move down to local level with considerable clustering of preferred suppliers at local level although there are still very few PCTs  with just two suppliers  (12) and even fewer with just a single system(3) But again we can expect further consolidation at a local level driven by GP Consortia

However, many PCTs have a dominat supplier as shown in the graph below with half of PCTs having a single supplier with more than 70% market share in the PCT.

The position looks quite different between the North and South with TPP SystmOne (yes there is no “e” ) having made significant inroads in the North, thanks to it alliance with the Northern LSPs in the NPfIT, but have made little progress in the South. In the new world of GP Consortia the influence of the NPfIT will be reduced and It seems doubtful if TPP will continue its rapid growth although I expect to see continuing modest growth in market share.

My data outside England is less complete, but interesting things are happen in Scotland with EMIS and INPS finally replacing the NHS funded GP system GPASS. Contracts are in place and EMIS will take 55% of Scotland while INPS will take 45% and the transition is now well underway.

There seems little opportunity for new entrants in to the GP system market and I don’t expect to seen until we see a radical reconfiguration of health IT which I think will see a move to cloud computing, with the development of a range of service in the cloud supporting a proliferation of apps which will be not concerned with the boundaries between care settings or particular healthcare organisations.

Exploring Social Media in Healthcare

On the 15th and 16th of April the BCS Primary Care Group will be running a Special Interest Group meeting to look at the role of social media in healthcare

PHCSG has been running SIGs (known as CLICSIG for reasons almost lost in history) at the rate of 4-6 per year for 30 years and this format has proved a very effective one for allowing us to explore an issue of current interest in-depth.

The meetings operate under the Chatham House Rule and are restricted to BCS members and sometimes invite guests who can bring special expertise. Typically 15 -25 members meet on Friday evening for informal discussion over dinner with a more formal session on the Saturday. Outputs are written up and inform future BCS work and policy and are usually published through a suitable channel.

Our next meeting is being facilitated by Ian Herbert and myself. We want to explore how social media might be used in healthcare. We are also interested how the PHCSG might use social media for its own purposes, both because we believe this would directly beneficial and also because we hope such use will help us better understand how social media can be applied more generally. At the meeting I will be exploring the ideas in my recent blog “Dr Finlay’s Facebook” and other group members will be contributing their ideas. Given that social media is a young person game we are planning to invite some of the younger generation to join us.

If you are a PHCSG member you might like to attend details from jill@phcsg.org if you are not you can join, or if you think you could bring special expertise and would like to attend as a non-member get in touch with me.  There is no charge for the event but those attending pay their share of room hire for the event and their own accommodation and subsistence.

We hope to present the outputs of this work at the PHCSG Conference on 10/11 May www.primaryhealthinfo.org

Tonsillitis Pen V

What you might have seen in a GP record circa 1980, if you could have read the handwriting!

Early GP computing was fighting the hardware. How could we get 6000 patient records on a  pair of 8 inch floppy disks (well under 1Mb)?  The terse style of GP records gave us a chance, particularly if you could compress this rich clinical narrative into a couple of 4 byte Read codes   “H14, e151″)

Things got easier you could get a 10Mb hard disk for under £5k and we could afford a bit of free text – “Tonsillitis (probably) Pen .V and thus was born the computerised GP record that survives to this day. A structure coded, record, with text used occasionally to clarify or maybe confuse what w e meant by the code “Carcinoma of the Broncos (B192) Excluded (Text)” an approach driven by the limitations of the hardware but one that fitted with the GP approach to record keeping and led us to discover the power and flexibility of a structure record built on a terminology – What to record some new stuff, no need to change the software just add a few codes to the terminology.

This paradigm has served GPs well and continues to do so, codes first, text an afterthought. However, trying to extend this approach into other areas of healthcare where there is a need to record a richer narrative has been a challenge, spawning ever more complex terminologies (SNOMED) and complex structures (ENV 13606, HL7 V3, OpenEHR……) the holy grail has been semantic interoperability, computable, interoperable records. In my view this remains a noble pursuit but one that fits poorly with the alternate paradigm in much of secondary care where the clinical narrative (text) comes first and coding is an afterthought, probably done by someone else for purpose not directly related to the delivery of care.

Today I detect a new zeitgeist, which might provide a way to combine these two worlds. The priority now seems to be to put the right information in front of the right person at the right time in an eye-readable form. This takes us to a document-centric view where all you need is some computable metadata to route the document. However, while this approach offers many benefits over paper, it perpetuates records based on forms, scales, assessments and unstructured clinical correspondence which hardly unleashes the power of computerised records. Those leading the development of records in secondary care understand this and we are now seeing the development of records standards which apply some high level structure (headings) to create semi-structured clinical narrative. For those in secondary care this is useful progress and will hopefully facilitate the electronic sharing of clinical records but also, and more excitingly, help them understand the clinical benefits of coding parts of this clinical narrative.

What I hope to see as the next phase in the development of electronic records are records which support a rich clinical narrative, structured so that we can get the right information, in front of the right person at the right time, but also coded, where this is useful and practical, so that we can start to explore the possibilities that flow from computable semantically interoperable records.

Dr Finlay’s Facebook?

The marvellous phrase comes from the Demos publication “the talking cure why conversation is the future of healthcare”  by Jack Stilgoe and Faizal Farook http://bit.ly/e0GUAD They use it to describe the changing relationship between internet enable patients and doctors. I have stolen it as shorthand for a new online environment that I think we need to create that harnesses social networks to manage virtual and physical care and link formal and informal care networks. This is certainly not a Facebook application and I probably need to find another name.

My ideas on what I mean are still developing, but what I’m trying to describe is something that combines some of the features we see in social networking tools like Facebook and Linkedin with facilities that might be provided by a patient portal providing access to knowledge and services and tools to allow patients to create their own records and access and contribute to the records about them held by others.

This environment also need to integrate physical and virtual care managing the handovers between the two, with facilities for secure consultations between patients, their informal care networks and the Health Care Professionals providing formal care. The environment also needs to support a privacy and governance model that allows patients to share and protect their information as they wish for both primary (their direct care) and secondary purposes (uses not essential for their direct care such as medical research).

This environment needs to be open and controlled by nobody while allowing patients to control how their information and healthcare are managed. It needs to provide a technical platform that can facilitate the exchange of information and access to services and support the creation and deployment of a myriad of applications and devices to support health, wellbeing and care.

We see many developments that might form part of this environment the www.connectingforhealth.nhs.uk/systemsandservices/spine , www.google.com/health , www.healthvault.com , www.emisaccess.co.uk , www.patientslikeme.com , www.patient.co.uk But still have some way to go. Do others share this vision? How can we take it forward.

Medication Concordance

I’ve been doing some work concerned with patient concordance with medication in UK General Practice and have just completed a quick trawl through the literature.

I knew that patient concordance was not good, but what I see is truly worrying with data showing that  only about 40% are still taking the prescribed medication after 3 month across a range of treatments which one would expect to be long-term if not life long where poor concordance has serious sequelia.

People drop out at all stages of the process and while not all of the dropouts are easily visible to healthcare professionals much of it would be apparent from patient’s failure to request/collect repeat scripts or in the pharmacy where medicines dispensed go uncollected.

IT systems in both GP and pharmacy can easily identify these non-concordant patients but these does not seem to happen as much as might be expected, maybe in part at least because of the work involved in addressing the problem and the patchy success of attempts to do so reported in the literature.

The long-term cost of poor concordance in financial terms and in terms of morbidity and mortality is considerable and focused efforts at improving concordance should have a strong economic case. However, we see a problem here that inhibits many potentially quality improvements in the NHS namely that demonstrable cost savings don’t occur either in the budgets or timeframes that matter to those designing and delivering services. With the prospect of it doubling the drugs bill savings year hence or in someone else’s budget are not very alluring to commissioners.

Will things be different in the new world of GP Consortia? Maybe GPs commissioners  will be better placed to look at whole system costs, but I doubt they will welcome short-term cost hikes for long-term savings. Solving this problem, which affects not just medicines but a whole raft of technological innovations and non-technological service redesign, requires a new approach difficult to imagine in a cash-limited age of austerity. In the case of medicine maybe the industry can help with pricing approaches that reduce short-term cost in return for a share in long-term savings, but implementing such new approaches in the context of UK pharmaceutical price regulation is probably beyond the scope and ability of GP Consortia.

Existing IT systems in GP and pharmacy can help us identify non-concordance and we have evidence to inform interventions more likely to be effective. The Electronic Prescribing Service missed the opportunity to provide dispensing feedback to GP, but could be easily updated to do so and the Internet and mobile –devices offer new low-cost approaches to gain concordance. However, unless we create an environment that creates incentives to act I doubt we will make much progress.

I’m happy to share some of the literature once I have it consolidated, but for now here is a single paper which reviews much of the work