England's NHS Care Records Service (CRS) is one of the most recurring subjects discussed in the UK health industry. Yet many industry insiders struggle to differentiate between the CRS and Summary Care Record (SCR), let alone realise the benefits that it could offer. (The SCR is just a scaled down version of CRS, which excludes detailed and sensitive patient information.)
Others believe that CRS was doomed to failure from the very beginning, like most of the National Programme for IT (NPfIT). The perfidious mainstream media has helped to instil this perception into health professionals as well as the general population.
But the Department of Health (DH) and its executive agency Connecting for Health (CfH) are to also blame for this. NPfIT was approved without any truly independent consultation or a benefits realisation exercise. As a consequence, many systems are disparate, enormous delays are occurring and most health professionals do not understand how the initiative could help them to improve their work and quality of care for patients.
The roll out of CRS was expected to start in 2004, along with other elements of the NPfIT such as the N3 broadband network and the Picture Archiving and Communications System (Pacs), but it only began to take place in 2007.
The delay has been attributed to problems with software packages and a lack of definition around access levels and security standards. It was originally scheduled for completion in 2010-11, but at present it has is no provisional completion date.
A report by Parliament's Public Accounts Committee published in January 2009 found that the Lorenzo care records software had not gone live throughout a single acute trust by August 2008. Lorenzo is provided by iSoft and the CSC Alliance to trusts in the North, Midlands and East region, which covers 60% of England. Single digit deployments had taken place amongst acute trusts in the other two regions, London and the South, by the same month. These regions use Cerner Millennium software.
Lorenzo has four release versions, while Cerner has two 'integrated' release versions. These releases serve various administrative and clinical purposes. They all have different technical requirements and their deployment is separate, which renders the CRS implementation schedule more complex and lengthy.
Fujitsu's early contract termination in the South is also contributing to delays, as CfH decides who should take over from the Japanese company.
Wide area network
Under current plans, more than 120,000 doctors, 400,000 nurses and some administrative staff will have some level of access to CRS. A government white paper published in April 2007, entitled Pharmacy in England: Building on Strengths, argued that 10,000 pharmacies would eventually be given access as well.
If this trend continues, a further 20,000 optometrists and dentists could follow suit, which could represent sizeable data amalgamation and systems integration opportunities for suppliers. But it could also represent an extra degree of complexity and hence further delays to NPfIT.
The care record environment becomes even more complex when social services and local authorities step into the picture. The government realises the benefits of joining health and social services, but it does not fully understand the challenges.
A consultation entitled Common Assessment Framework for Adults, published by the DH in January 2009, highlighted some of problems in dealing with data in the health and social services sector, and it pinpoints many of the difficulties that the Care Records Service is already facing.
It recommends that health organisations should share information with their social services and local government counterparts. It remains unclear when and how the DH will implement these proposals and recommendations. Government consultations often have the effective ferocity of a moth taking on a light bulb.
The CRS must overcome many serious issues – including information duplication, poor data sharing, ineffective data cleansing and patient consent – before health organisations even begin sharing information consistently with social services and local authorities.
Kable believes that CRS will eventually deliver extensive benefits to the health community, and that one day this may be mirrored in other areas of the public sector. These benefits include the ordering of tests and of patient-based services such as physiotherapy and nursing interventions, support for managing referrals, waiting lists, scheduling, health screenings, prescription management, stock management and even commissioning services, to mention just a few.
But it is very difficult to establish when this will happen.
CRS has so many functions, and the complexities are such, that it is also difficult to attach a price tag to it. The fact that the suppliers CSC and BT are free to negotiate with CRS subcontractors iSoft and Cerner at their convenience, and are not obliged to disclose contractual terms, adds to the difficulty.
It will take time until health professional realise the full benefits of CRS. In the meantime, the media will continue to remind us of the delays, the disproportionate costs and the mistakes made along the way.
The 'big-bang' approach taken by the DH – whereby little or no regard is paid to past failures and a monstrous project is launched based on the naïve assumption that huge investments invariably translate into success – is largely to blame for this.
