Systems integration

A lateral approach to systems integration

April 2007

Ascribe’s Simon Mehlman and Gary Mooney propose an alternative to NHS Connecting for Health’s approach to systems integration.

Simon Mehlman

For the vision of electronic healthcare records (EHRs) to become a reality, there needs to be a means by which automated interactions between the computer systems in different healthcare provider settings can be carried out.

Over the last 10 years or so, there have been many explorations — by both governments and industry — of ways in which to achieve this goal. Each solution requires some form of standardisation.

NHS Connecting for Health’s implementation of England’s National Programme for IT promotes the concept of a monolithic software platform that will, from one application, address the needs of the entire healthcare service. In its current form, however, it has reduced the range, richness and diversity of software solutions available to NHS trusts and met with strong resistance from healthcare professionals not prepared to change local best practice to accommodate a computer system designed without consideration for their individual needs.

The Government estimates the total spend on the NPfIT will be £12.4bn,(1) but Private Eye recently reported that some observers expect a much higher figure: £40bn.(2) In recognition of this massive investment and the reported lack of benefits being delivered, CfH is being increasingly challenged by the media,(2) healthcare professionals,(3) economists,(4) and politicians.(5)

This article proposes a systems integration approach between existing and established ‘best of breed’ healthcare software solutions as an alternative to the CfH approach. This, we suggest, could help realise the goal of a patient-centred healthcare record both more efficiently and more effectively, while building on best practice already established locally.

There are a growing number of successes in the field of systems integration, based on new integration technologies and international healthcare information standards such as Health Level Seven (HL7). Such examples suggest that, if carefully scaled and addressed, the concept of a patient-centred EHR could be achieved rather more cost effectively than through the CfH programme.

The single-system approach The proposition of a single and centralised system is initially tempting. Like any large network, there are time and cost benefits to standardised deployment — including rapid distribution of upgrades, consistency in training, upgrades and reporting. In fact, if you had just landed on a new continent with no existing infrastructure, adopting a single platform would make a lot of practical sense.

The reality, however, is somewhat different: in the last two decades there has been a phenomenal uptake in the use of computers across all aspects of healthcare. In our view, the Government’s plan for a single integrated system is fundamentally flawed because it does not take into account two key aspects: existing systems and the essential purpose of a healthcare system.

Existing systems

Our current systems are so lacking in integration that when patients are discharged from hospital, their GPs may or may not be informed of their stay, their diagnoses or even their treatment and medicines. We currently face a gamut of day-to-day problems arising from the fact that our current healthcare systems are not well integrated.

Many of these systems have taken over 10 years to develop, but to propose replacing them with a single system fails to take into account both the sheer scale and complexity of the problems and also the cost and chaos of replacing everything that has come before.

In attempting to introduce a new centralised IT system, the Government’s approach has been akin to a road contractor whose remedy for traffic congestion in cities in towns is to rip up any roads laid out in a haphazard way, and bestow a new grid-based road system ‘to speed things up’. Any issues arising out of what commuters are to do while this reconstruction takes place seem unimportant in light of their vision of a better tomorrow — and this leads to the second fundamental flaw in the plan for a centralised healthcare IT system.

Improving reporting standards and using technology to provide greater healthcare ‘choice’ may well be laudable goals; but the purpose of a healthcare system is — is it not — to improve the health of the patient. If proposed healthcare systems are not focused directly upon helping clinicians provide the best care to their patients, then the system is not working.

We therefore need to consider how we can improve communication and integrate the systems currently in place. This realisation is not without its own problems. While integrating new systems allows developers to create data exchanges that are purpose-built, integration of existing systems presents a new challenge: how to define a set of criteria for exchanging healthcare information easily and quickly for everyone who needs to know, when they need to know it.

The decentralised approach

This approach accepts that there is no single ‘magic bullet’ or ‘killer application’ when it comes to integrating healthcare systems. It can also deliver genuine improvements in healthcare by using existing systems instead of replacing them. Clinicians and administrators should not need to relearn all their IT skills when a new piece of IT infrastructure, such as electronic prescribing, is introduced into their daily working routine.

The key to systems integration in healthcare is to understand that healthcare providers want to focus on improving their patients’ health and it’s the job of informaticians to combine new and existing systems to provide clinicians with a painless transition to any new solutions.

Integration between disparate systems is more easily achieved when they exist within a single domain; it can provide an electronic patient record (EPR) such as for a GP practice or a hospital. The real challenge comes in integrating systems across these domains to provide a single healthcare record, since the design of the system needs to be organisationally independent and the patient’s permission needs to be sought.

The National Programme offers us a real chance to standardise the interface and relationships between systems. The key is to offer standards on data exchanges that are independent of the processes in healthcare.

Data sharing can be achieved by agreeing message standards; HL7 is a good start. Coding standards should not dictate that any single coding system is used within a system, only that appropriate codes can be used to populate the messages sent to other systems.

Not only can new systems be integrated with existing systems but it is also practical to combine products from several companies to provide a ‘customised’ integrated solution from several providers. To do this may require the development of a ‘common interface engine’ or similar translator, but once this is in place, there is nothing to stop additional modules being created and grafted on seamlessly, to grow with the healthcare providers’ local requirements.

Ultimately, as long as the focus remains on the health and welfare of the patient, the decentralised model will continue to provide ‘best of breed’ solutions, as they are required, when they are required, for the healthcare sites.

One hugely significant offshoot of this is that, subject to planning and implementation, you can buy an integrated healthcare system today. In hospitals throughout the UK, such systems support the interoperability of disparate applications and processes and help to improve patient safety When a hospital can easily track patients through their stay and treatment, and then share that information with the patients’ GPs or treatment clinics, patients will start to benefit from the same kind of joined up processes they take for granted when banking or travelling. And ultimately that’s what an integrated system for healthcare is all about.

Conclusion

In recent years, the Government has driven healthcare IT systems down a mandated route that has provided financial gains in some quarters but has yet to deliver significant or effective systems on anything more than a piecemeal, highly publicised basis. The issues that face our IT infrastructure in England’s Health Service cannot be treated as a single entity requiring a single, centralised government-imposed solution: because there is no single problem and there is no single treatment that can be prescribed.

Reports are now appearing in the media that suggest the Government has now recognised the need for decentralised (integrated) systems and that more developers from the private sector will soon be recruited as accredited software solution providers to deliver healthcare IT solutions.(8)

Decentralised integrated IT systems can provide flexible solutions and when combined with a common set of communication standards, they not only provide a basis for the best fit for the future of healthcare, they can deliver a robust and effective solution, today. By agreeing on standards for interoperability and embracing integrated systems we can build upon our British culture of creativity and innovation to focus on the genuine healthcare needs required by clinicians and deliver a patient-centred healthcare record shared and owned by the patient.

Simon Mehlman, Group Marketing Manager, Ascribe plc.
Gary Mooney, Group Operations Manager, Ascribe plc.

References

1. National Audit Office. Department of Health: The National Programme for IT in the NHS. Executive summary. London: National Audit Office, June 2006. www.nao.org.uk/publications/nao_reports/05-06/05061173es.htm  [accessed 30.3.07].

2. Fleming N. Computer plan for NHS two years late and three times the cost. Telegraph.co.uk 31 May 2006. www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/05/31/nfarce231.xml [accessed 30.3.07].

3. Bowers S. NHS £6bn IT system poor value, say experts. The Guardian 22 January 2007. http://business.guardian.co.uk/story/0,,1995651,00.html  [accessed 30.03.07].

4. Bowers S, Carvel J. Spending watchdog to reopen inquiry into NHS computer overhaul delays. The Guardian 5 September 2006. http:// business.guardian.co.uk/story/ 0,,1864956,00.html [accessed 30.03.07].

5. Hencke D. MPs warn of 70 failing Whitehall IT projects. The Guardian 5 July 2005. www.guardian.co.uk/guardianpolitics/story/0,,1521324,00.html  [accessed 30.03.07].

6. National Audit Office. A spoonful of sugar — medicines management in NHS hospitals. London: National Audit Office, December 2001. www.audit-commission.gov.uk/reports/ac-report.asp?catid=&prodid=e83c8921-6cea-4b2c-83e7-f80954a80f85  [accessed 30.03.07].

7. Smith J. Building a safer NHS for patients: improving medication safety. London: Department of Health, January 2004. Gateway reference, 1459. www.dh.gov.uk/assetRoot/04/08/49/61/04084961.pdf  [accessed 30.03.07].

8. Bowers S. NHS seeks rival IT firms as trusts lose faith in iSOFT. The Guardian 5 March 2007. http://society.guardian.co.uk/health/story/0,,2026498,00.html  [accessed 30.03.07].