Evidence submitted by Computer Sciences
Corporation (EPR 46)
1. This submission is made in response to
the invitation by the House of Commons Health Select Committee
to submit evidence on "The Electronic Patient Record and
its use".
2. Computer Sciences Corporation (CSC) is
a global information technology (IT) services company. Employing
over 70,000 staff throughout Europe, the Americas and Asia, CSC
has enormous experience and track record in major IT programme
delivery and assurance for leading private sector multinationals
and large public sector organisations.
3. In 2003 CSC was appointed by NHS Connecting
for Health as the Local Service Provider (LSP) for the North West
and West Midlands cluster and has more recently (as from 8 January
2007) assumed LSP responsibilities from Accenture plc across two
additional clusters—the North East and Eastern clusters.
4. As the largest Local Service Provider,
with experience of successfully delivering healthcare systems
globally as well as part of the NHS National Programme, CSC is
extremely well placed to provide evidence to the Committee on
the role and use of the Electronic Patient Record and the significant
benefits that this will provide for patients and clinicians alike.
5. As a Local Service Provider CSC acts
as an integrator, providing systems which support healthcare in
both hospitals and GP surgeries and which interface to national
applications such as Choose and Book and the Spine (the latter
through which the National Electronic Patient Record will be accessed).
CSC delivers systems across a wide range of care settings including
acute trusts, mental health trusts, community hospitals, child
health settings and GP practices, working with NHS staff on the
frontline to ensure benefits of these new systems are fully realised.
6. In the North West and West Midlands (NWWM)
cluster (which includes the North West Strategic Health Authority
and the West Midlands Strategic Health Authority) CSC has successfully
deployed over 70 Patient Administration Systems (PAS), 10 Picture
Archiving and Communication Systems (PACS) and 10 Radiology systems
across hospital trusts, with a total of nearly 50,000 registered
NHS users to date. More than 950 individual sites have been provided
with access to systems provided through the National Programme
for IT. The PAS systems have laid the foundations for improved
patient care by: Supporting national initiatives such as the reduction
of waiting times and greater patient choice; supporting Choose
and Book; and providing reliable accessibility 24 hours a day,
seven days a week. The PACS systems have enabled diagnostic images
such as X-rays and scans to be stored and viewed electronically,
so that doctors and other healthcare professionals can access
the information and compare it with previous images at the touch
of a button. This delivery of efficient image processing will,
by 2008, directly help contribute to meeting the NHS objective
of a maximum 18 week wait, as well as providing the obvious benefits
of faster and better diagnosis.
7. In the North East and Eastern clusters
significant progress has also been made across a number of healthcare
settings. 550 GP surgeries now have new systems which will help
reduce time spent on administrative processes and will support
increased patient choice with Choose and Book. Best practice diagnostic
tools, such as "Map of Medicine", are providing clinicians
with access to specialised clinical knowledge whilst child health
systems are providing a continuous record of the health of a child
from birth to age 19, putting to an end paper-based vaccination
and examination results.
8. As has been well publicised, however,
the delivery of parts of the programme, including the systems
being deployed by the Local Service Providers, has not been in
keeping with some of the ambitious early plans. What must be made
clear, however, is that this is a ten year programme and the size
and complexity of what is being delivered is breaking new ground.
The technology itself is not cutting edge but it is bespoke to
the NHS and the National Programme for IT. What is cutting edge,
however, is the deployment of technology across an organisation
as complex and far reaching as the NHS. Delays and re-planning
have arisen as a result, but it is the firm belief of CSC in this
submission to the Committee that not only has much been learned
and delivered over the past three years, but the future benefits
which will be further derived from this programme will save lives,
improve patient care, provide patient choice and provide our National
Health Service with massive cost savings over the Programme 10
year horizon as well as into the future.
9. Central to the National Programme and
the Health Select Committee investigation is the Electronic Patient
Record. The record will exist on two levels: A locally accessible
"Detailed Record" and nationally accessible "Summary
Record".
10. The bulk of detailed patient information
will be held and stored locally at the GP and "local health
economy" level. Instead of having fragmented health records
in different places, NHS organisations in a local health economy
will be able to share a Detailed Care Record for a patient. This
includes details of medication, X-rays, operations and a history
of medical conditions. This is already being put into place with
significant benefits to patient care.
11. Ensuring privacy is, of course, at the
forefront of the Electronic Care Record implementation. Organisations
that need to access patient information will need to first be
authorised by a Registration Authority. Once authorised, individuals
(whether care professionals for clerical staff) will be issued
with a smartcard which will govern what level of access they are
granted. The card itself is similar to chip and pin credit cards
and can be printed with the name and photograph of the user. The
card contains a unique user identity number. Individuals will
only be given access to the patient information that is appropriate
to their work and level. As an example, a receptionist will be
given limited access that will allow for appointments to be booked
for a patient, but would not be provided with a patient's full
clinical record.
12. Patients will be able to opt out from
sharing data outside the organisation that is providing care.
Such opting out will prevent clinical information collected in
one healthcare setting being made available to another, other
than where it is specifically communicated as part of a correspondence
between clinicians involved in the treatment of the patient. Such
opting out needs to be made by an individual in the knowledge
that to do so may result in less effective treatment or even an
increased risk of harm as decisions on future treatment may be
based on a less complete clinical picture.
13. It is also important at this juncture
to overview the concept of "Sealed Envelopes". A patient
will be able to request for specific information to be accessible
only when direct consent is given. This will be explained to patients
and a campaign is being planned by the NHS that will explain this
process in full. In addition, clinicians will be able to restrict
what is viewed by patients where sensitivities exist—for
example, confidential parts of their record which relate to a
third party.
14. The national Summary Record will be
pulled from the detailed record. This will show high level medical
information such as details of current medication, allergies and
other health issues. Its primary purpose is to support treatment
of the patient when their (locally held) detailed record is not
needed, or not available. This might happen for example, if the
patient is taken ill on holiday, or needs to be treated in an
emergency. In the future, the Spine, the central mechanism for
accessing patient information, may allow for a transactional way
of obtaining detailed patient information remotely and in this
way act as a "bridge" between local or regional systems
i.e. not storing the detailed patient record itself but "knowing
where it is stored".
15. There are legitimate concerns over the
security and privacy of highly sensitive personal data when it
is stored on computers, and when a number of smaller systems are
aggregated together into fewer, larger ones. The National Programme
for IT is installing IT systems which are shared across a number
of care settings, in order to provide a joined-up health service,
whereas today the majority of IT systems are dedicated to one
individual care setting, for example a GP surgery or an acute
hospital. CSC is responsible for the provision of regional systems
which contain detailed clinical information about patients and
would therefore wish to address these concerns directly.
16. In all respects, we believe that the
level of security and confidentiality of patient data held within
our systems is considerably higher than in the systems that we
are replacing, and of course, over the paper based systems which
are almost ubiquitous in secondary care today. Regarding security
and confidentiality, we would make the following additional points:
(i) The systems provided by CSC are hosted
in secure data centres, rather than locally on NHS premises as
are many of the current systems.
(ii) All data transmitted over the networks
between the CSC data centres and NHS premises is encrypted using
approved encryption techniques.
(iii) Before commencing live operation our
systems are subject to specific security testing and penetration
testing—which includes "ethical hacking". These
tests are approved and witnessed by external parties through NHS
Connecting for Health.
(iv) Our applications enforce strict access
controls to patient data through several levels of security. This
starts with smartcard access to systems as described in paragraph
11 above. Access to data is then restricted based on the role
of the user. A ward clerk, for example, would not see any clinical
data. Further restrictions on access are then applied so that
the user must be involved in the patient care in order the gain
access to data. It should be remembered that the professional
code of ethics of NHS staff, together with NHS policy enforcement,
is at least as important as the technical and physical security
measures used.
(v) The new systems we are installing maintain
an audit trail which keeps a record of who has accessed patient
data. This is possible because the smartcard log-on uniquely identifies
the person who performed each action using the LSP systems.
(vi) All CSC staff that support NHS systems
containing identifiable patient data are security cleared to at
least SC level 2.
17. The benefits to be derived from this
system are numerous and are central to the motivation for this
programme. The ultimate benefit for patients is better, safer
healthcare through clinicians having more complete, more accurate
information about them and reduced waiting times. Care professionals
and clinical staff will have easier access to up-to-date information
which will improve diagnosis and treatment. They will also have
a lower incidence of lost records and test results and will be
able to access patients' records from more than one place. For
the NHS, improved availability of information, reduced duplication
of effort and streamlined business processes will increase efficiency
allowing better use of scarce and expensive resources. Cutting
down on the filing and storage of paper files will result in real
cost savings and care will be delivered to a higher and safer
quality. Ultimately patients benefit when decisions made about
their care are based on accurate, up-to-date information. Too
often, with the current plethora of disparate healthcare systems,
this is not the case.
18. The National Health Service in England,
however, is not alone in acknowledging the benefits that are to
be gained by going from a system of paper patient records to one
of electronic based records.
19. In the Netherlands, CSC is responsible
for the build and maintenance of a system comparable to the Spine.
The initiative launched in 2003 is the foundation of a country-wide
roll-out of an electronic patient record (EHR) that is being developed
under the direction of the Dutch National ICT Institute for Healthcare
(NICTIZ). The system, known as the National Switch Point for Healthcare,
makes it possible for patient information to be accessed and supplemented
from anywhere in the country. The motivation for this Programme
can be seen in research provided by the institution of pharmacists
in the Netherlands (WINAp) which estimated that there are 90,000
hospitalisations a year which were a direct result of avoidable
medical errors. In addition to this, research carried out by TNS-NIPO
(a market research company) for NICTIZ shows that approximately
800,000 Dutch people over the age of 18 have been victims of errors
due to the inadequate transfer of medical information.[36]
Given the total population of the Netherlands in 2006 was estimated
at 16.5 million, both of these statistics are significant. Similar
to the Spine in England, access is only provided to physicians
who have the relevant smartcard that authenticates identity. The
system successfully went live in January 2006 and early adopter
sites have already been connected to the system allowing for remote
access to patient records.
20. Looking elsewhere across Europe, Denmark
is perhaps the most advanced country in terms of utilising electronic
records. More than 95% of GPs are using electronic medical records
in their practices and there is 100% electronic access to hospital
discharge letters, referrals to specialists, lab results, billings,
prescribing, home care and pharmacies. Through Scandihealth, its
wholly owned subsidiary, CSC has been actively involved in developing
healthcare applications applications, and is responsible for systems
which support the management of approximately 70% of hospital
beds and Clinical Records throughout Denmark. A study into the
Danish system by the Canadian government agency (Canada Health
Infoway) charged with delivering electronic health records showed
that doctors saved on average 50 minutes each, per day, that had
previously been spent contacting hospitals to seek clarification
or track results. Electronic prescriptions meanwhile have been
credited with cutting medication problems by more than half and
labelling errors in labs to almost zero.
21. In Canada, the Health Infoway has been
charged with accelerating the implementation of electronic health
information systems. Their mandate is to provide for 50% electronic
records by 2009 and 100% by 2010. The implementation of this is
well underway with provinces such as Alberta and Newfoundland
are successfully leading the way and realising the benefits of
quicker and more accurate access to patient records.
22. In the US, CSC is at the forefront of
an initiative, supported by over 100 public and private organisations
to determine the approach to developing a national care record
system appropriate for the US health economy. Similarly in France,
CSC is actively involved in a new programme, in the early stages
of development to create a national patient record system. Both
countries are referencing the UK in this regard.
23. The adoption of Electronic Medical Records
is now a global trend and one which is motivated by widespread
benefits to patients and healthcare professionals alike. While
concerns of privacy will continue to be debated with vigour we
must ask ourselves if a stack of patient case notes left in a
hospital corridor are more protected than the stringent security
measures which will be provided by this programme, if doctors
time and the money of the NHS must continue to be wasted on paper
medical records, or if, and perhaps most importantly, the safety
of patients must continue to be placed at avoidable risk in the
21st Century?
Computer Sciences Corporation
16 March 2007
http://www.nictiz.nl/uploaded/FILES/Corporate%20communicatie%20English/corporate%20profile.pdf
36 Refer to Dutch National ICT Healthcare overview: Back
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