International

Britain’s Tories say they will cancel giant EHR

LONDON, U.K. – Britain’s Conservative Party is threatening to scrap the country’s $12 billion healthcare IT system if it wins the next general election. The Tories have been critical of the massive electronic health record program, which has been plagued with difficulties and is running four years late.

In August, Stephen O’Brien, the Conservative party shadow health minister, published an independent review of NHS IT systems. Promising an end to the Labour government’s centralized approach to information management, he said the Tories would give patients more control over their own medical records.

In particular, he said that electronic records could even be held on internet-based systems run by companies such as Google and Microsoft.

As well as renegotiating “local service provider” contracts between contractors and the regions of the NHS, Mr O’Brien signalled that some parts of the current system will be abandoned outright.

The central “spine” connecting all parts of the NHS and allowing patient records to be accessed from anywhere in the service would be scrapped, Mr O’Brien said, saying that his review had identified little demand for universal access to health records among NHS workers.

When the British healthcare IT programme was first bruited about in 2002, under the Labour government of Tony Blair, the idea of a full patient record, available anywhere in an emergency, was the principal political selling point for what was called “the biggest civilian computer project in the world.”

The aim was to give all 50 million or so patients in England (the rest of the U.K. is working out its own strategy) an all-encompassing electronic record. Roll-out was meant to start in 2005 and be completed by 2010.

Under a Conservative government, development of the local record – exchangeable between primary care physicians and their local hospitals – would continue. Nationally, clinicians would still be able to seek access to it when needed from the doctors who would hold it locally.

But the idea of a national database of patients’ records, instantly available in an emergency from anywhere in the country, would disappear.

According to a report published in the Financial Times, for many clinicians, the idea of an instantly available national record was never seen as a necessity. It is access to a comprehensive record locally that is crucial for day-to-day care.

Nonetheless, the Conservatives’ decision to scrap the central database is a symbolic moment for a £12billion (US$20 billion) programme that has struggled to deliver from day one. It is currently running at least four years late – and there looks to be no chance in the foreseeable future of its delivering quite what was promised.

So what went wrong? Too much ambition, too much speed, too much centralisation, too little local ownership and not enough choice have been just some of the problems.

“It is more difficult than people think. But I do think that by now, seven years on, we would have been further forward,” said Dr. Glyn Hayes, former chairman of the British Computer Society’s health section.

Running a huge, centralized project is seen as a major problem. In IT, the bigger the project, the higher the chances of failure – that is, running late or over-budget. Or worse still, not being used, after all the time, effort and money has been expended.

“The arguments for centralization were first that all these systems had to be able to talk to each other,” says someone who was closely involved in the government’s original decision to launch the programme. “Second, there were powerful arguments for economies of scale if the system was bought centrally. And, third, the NHS had a long history at local level of taking money earmarked for IT or other projects, and finding ways of spending it on something else.

“Looking back, it was the wrong thing to do. It was right to centralize standards for communication and for what should be in the record. It was right to use centralized purchasing power. But the next step, that the whole programme had to be centralized, did not have to flow from that. It proved to be a mistake.”

With a staggeringly ambitious goal to get the first electronic records running just three years down the line – when what was to be in them had yet to be fully defined – Richard Granger, the then director, decided that the fragmented and small providers of IT still in the NHS hospital market did not have the scale or industrial muscle to deliver.

But there were problems with large companies that won contracts to supply solutions. The US company Cerner had good clinical systems. But software designed for hospital billing systems in the US needed a big rewrite to run all the administration and reporting functions of the NHS.

Conversely, iSoft, which at the time was a British company, knew how to run the administrative side of the health service but lacked a clinical record. It has taken years for the often troubled company to come up with one. The first deployments of early versions of it are only just under way.

Moreover, while there was a £6billion budget for the 10-year central contracts, no money was dedicated to training, in spite of the lesson, from the relatively few successful installations of electronic records in US hospitals, that at least as much has to be spent on changing the way staff work as is spent on the systems themselves.

Furthermore, there was no local ownership of the programme. Local developments of electronic records that were under way were halted. The national programme became something that was delivered from on high to hospitals and clinicians, not something that they chose or voted for. They also had to fund their own training and other costs.

So where does the programme go now? BT and CSC, the two remaining systems installers, have been given deadlines of November 2009 and March 2010 respectively to achieve a smooth implementation in a big acute hospital. Failing that, the department of health says it will “look at alternative approaches”.

Quite what plan B is, however, remains a mystery. Any decision to cancel the contracts is likely to result in mighty litigation. The hundreds of millions of pounds set aside to achieve an electronic record could go up in smoke in claim and counter-claim as each side blames the other.