Select Committee on Health Written Evidence

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

36   Refer to Dutch National ICT Healthcare overview: Back

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