Ed: "March 2001 was when the EPR Arms first opened it’s doors. Tell me about how the “EPR Arms” was conceived?" SB: "Well, the problem was I needed a vehicle which I could use to explain the (often) complicated detail of Health IT without it being too tecky-giga-bunky. Health IT was considered something that only geeks and nerds understood — the province of anoraks. There were some clinicians who were equally anoracky: they’d built their own clinical database which delivered supreme functionality to them and perhaps some of their mates. I referred to this group of folk as the clinoraks." Ed: "So how does this erh, vehicle help?" SB: "If I had to describe health IT to a senior manager or clinician, they would think I was patronising if I explained it in “Noddy learns about health IT” language. "However, if I were to have a group of non-NHS folk in a bar, and I had to explain, say, integrated care pathways to them, I could do it in such a way as to also make it concise and understandable to the senior NHS folk without them getting offended. This is how I intended to use this vehicle. This EPR Arms." Ed: "How many did you write?" SB: "Well, the first was in March 2001 and the last one was in March 2006 with Christmas and August off, so that is about 50 articles!" ED: "And why did you stop?" SB: "I think you will understand when you re-read them all. I was beginning to repeat some of the earlier themes as the issues were still pertinent and relevant. I didn’t like repeating them so I closed the bar down." Ed: "So in the first one, which is shown below, you started off with the Information for Health targets. Explain a bit about why that was so important at the time." SB. "For those that still don’t know, what Connecting for Health is trying to do now started way back, even before Information for Health in 1998. But IfH put down some specific markers or targets which could be used to measure progress." Ed: "The 6 levels of EPR? Everyone knows about these surely?" SB: "Although EPR was only one component of a very comprehensive Information strategy, the six level model for developing local EPRs was one of the great health IT icons. But you would be surprised to hear that not everyone does know about it. In a recent workshop of CfH staff in one of the clusters, a large number of the audience didn't know what a level-3 EPR was. And THAT is what really annoys folk who have been “doing” health IT for years. That all that was done in the past was either ignored or overlooked. My very first question in any interview for any person wanting to work for Connecting for Health would be “what is a level-3 EPR?” Not because I am nostalgic about the past or think we did everything right back then. It is because if they don’t know what has gone before, then they could never appreciate what has and has not been done or tried. What worked and what didn’t. And we all know that if we don’t learn from our history, we will make the same mistakes again." ED: "OK so let us read the very first EPR Arms article and we can carry on our discussion after closing!" SB "OK! Mines a pint!" The EPR Arms, March 2001 “Who was it who said: ‘Vision without action is merely dreaming. Action without vision is just passing the time of day. But combine the two and you can change the world?’” I asked my mate Richard in the bar of the EPR Arms the other night. (Richard, who wasn’t at the front of the queue when most things were handed out, works in a travel agent’s and still wears stripy tank-tops). “Nelson Mandela, why?” “I was thinking about Information for Health.” “Now I’ll have to phone a friend! So what’s information for health then?” he asked. And so I went on to explain about where we currently are with computerisation in the health service. It is good to talk to someone who doesn’t work in the NHS. You get a fresh outsider’s view, and he asks some very pertinent questions. “So tell me, how come the hospitals haven’t computerised yet? Everywhere else has. We’ve had a computer in our travel agent’s for over ten years.” I told him it was because it was complicated; difficult; not easy and risky. “But isn’t it risky not using computers?” he asked. ”Didn’t I read the other day about a patient being given penicillin or something and she was allergic to it? Couldn’t that have been prevented if you used computers?" “Erhm!”, was all I could reply. “And how come that GP chap, Shipman, could get away for so long with killing his patients? How come no-one was monitoring his death rates?" More “Erhm!” “So what are you lot doing about it then?” He asked and so I told him. I told him that Information for Health is the information strategy for the NHS — supporting the doctors and nurses by giving them information and computerised support. But you can’t do it overnight. This takes a long time. You have to change the way people work and that will hit resistance. Nelson Mandela was right. The vision we all have of how our NHS could look is, on its own, only dreaming. What made Information for Health different was that it outlined an action plan: a series of milestones for how this vision can and will be achieved. That brings with it another bag of problems: By setting specific measurable targets you invite the less visionary people to simply do enough to get a tick a box and get a pat on the head. The milestones are not the objective. A level-3 EPR is not the objective. But a level-3 EPR is a measure of how a site is progressing with its EPR. “Isn’t having health records on computers dangerous?” Richard asked, blowing the froth on his third pint. “I wouldn’t want people to know what my liver-function tests are! (or that he was the first successful brain transplant with a haddock, I thought.) I was about to say that his current paper record is just as vulnerable but the words caught in my throat. I settled on “Mmmm!” “So what are these target milestoney things then?” I explained the targets and described level-3 EPR. He mused over that for a while. Well, he went quiet I assume he was musing. “And what’s in this level-3 EPR thing?” “Ordering tests from the Path Lab on a computer from anywhere in a hospital.” “Do you mean you don’t already do that?” “No. It’s about sending the lab results back to the wards electronically.” “Do you mean you don’t already do that?” ”No! It’s about prescribing drugs on a computer at the bedside.” “Do you mean you don’t ...?” “No! ... And it’s about planning the care each clinician is going to give a patient and recording what they’ve done on a compu ..." “Do you mean you ...?” “NO!" (Over the next few months I would like, with your help, to take the lid off some of these issues and mull over them with my pals in the EPR Arms. Together we may not be able to change the world but we may at least make an interesting column!) ED: "And so started the EPR Arms articles in bjhc&im. A lot of water has flowed under that bridge and many more bridges have been built since this first EPR Arms article way back in 2001. How do you think we have progressed since the turn of the century?" SB: "I am a great supporter of healthcare IT. I honestly believe that the patient safety agenda (what used to be clinical audit then clinical effectiveness then clinical governance) cannot be delivered without robust and timely clinical information. The fundamental principle that we shouldn’t lose sight of, is that healthcare IT should support the clinical process in what we do. What we have done will then automatically be captured as a by-product of the clinical process." ED: "So how do you think we’ve done then?" SB: "It is very easy to be critical: so easy, many people do it. But if we cast our minds back to the late 20th century post IfH’s daffodils, we haven’t moved that part of the agenda on much at all. There has been a lot of hidden development work — the foundations if you like, but in regard to the Level 3 EPR with it’s generic clinical functionality including order communications and electronic prescribing and integrated care pathways, we have not moved very far at all. "In fact, we have moved so slowly with order communications that some trusts have decided they cannot wait for the strategic CfH’s solution and they have, at their own expense, put in an alternative solution. "More and more trusts are considering putting in non CfH’s products. This surely is the wrong way to go — but at the same time, understandable as trusts NEED this clinical functionality. Reducing the clinical risk of prescribing is one of the real clinical benefits to be gained for the NPfIT but, as we will see later in this series, computerising such a complex process MUST be done carefully as it has the potential to do more harm than good. Hippocrates would not like that now would he?" Ed: "Finally, what would you like the readers to react to the
EPR Arms column?" SB: "Well Ed..." Ed: "That’s actually short for Editor..." SB: "Sorry! Well, first time around, in five years I got THREE emails suggesting topics to cover. That was disappointing. I think this time will be different as it is in an electronic medium so once they have read the column they can fire off an email straight away … can’t you! "Oh and don’t forget — If we combine vision with action — we can change the world!" ~ If you would like to help change the world, email Sean now with your views and comments on the major issues at If you want to know more about NHS IT you should read this book:
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