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This is a colour figure to accompany the article Community spirit: Investigating how services fit with the communities they serve by Ruth O'Shaughnessy, Graeme Russell, Nancy Poulter & Tony Wainwright, which appeared in Clinical Psychology Forum 212 (August 2010).
OShaughnessy Figure 1 CPF212
This is an Appendix to Mike Berger's article New NHS clinical information systems: the challenge of diagnosis and other issues, which appeared in Clinical Psychology Forum 179 (November 2007).
A Quick Primer on NHS IT Developments
Michael Berger
NHS IT - The vision
The National Programme for IT has at its core several electronic facilities aimed at providing rapidly accessible information for clinicians and mangers. A key element is an electronic record for each NHS patient. This record will contain basic information, taken from GP and other records, and will be stored in several data warehouses or ‘clusters’ accessible from anywhere in the NHS via an electronic network called the ‘spine’. Another system, the on-line Choose and Book is intended to enable a GP to access several hospital departments to make direct appointments for patients. An electronic prescribing service, a clinical library of healthcare information and the most successful system so far, a Picture Archiving System enabling immediate access to digital images (X-rays, scans and the like), are among the other components of this vision. A study by the National Audit Office (NAO, 2006) estimated a cost likely to be £12.4 billion.
Confidentiality and data protection issue
It is intended that some data about every NHS service user derived from local healthcare records will be transferred to the individual client summary record. Access will be by carefully controlled regimes. ‘Smart’ staff identity cards will be one means of controlling access. Given the highly confidential nature of health, especially mental health information, it is intended that access to such data will commonly be restricted via the system of ‘privileges’, so that only those entitled to enter data and/or see sections of the stored data are allowed to do so.
To protect the confidentiality and restrict unauthorised use, the data are ‘encrypted’ - stored in a form that makes the content unrecognisable and exceedingly difficult to decode to all but legitimate users, for whom decryption will be automatic.
Issues of accuracy, confidentiality and related concerns are being addressed (NHS, 2006).
One option is for patients to get access to their records over the Internet to check for accuracy. Such a system is already operation enabling GP patients to see their records over the Internet (EHI Primary Care 106, 2007). Further, each patient will be able to block their GP records being uploaded to the warehouse and those who choose to can have a so-called ‘sealed envelope’ of data that contains their highly confidential information (NHS, 2007).
This envelope can only be accessed under certain special conditions by people with particular privileges, such as a Consultant in A & E when the patient presents as an emergency, either in their locality or elsewhere in the UK. (Given the worldwide web, there is no reason why access could not be international should the need the arise.)
Many issues remain, from the development of robust software that meets requirements of all users, to resolving the issue of sharing of information across agencies, the development of shared records, and gaining the confidence of clinicians and patients. Some of these issues have already been resolved at local level. At the time of writing, a major exercise is being undertaken to inform the public of NHS information technology developments and consult over arrangements regarding confidentiality (Health Committee, 2007).
Data, information, codes and database
Information about clients and their clinical features as well as information about clinical processes and outcomes is based on data, the basic elements. A specific gender or age, ‘low mood’, or ‘improved’ are instances of data which when interpreted constitute information. A collection of data about an individual constitutes record, which if stored on a computer system, is an ‘electronic record’. Multiple records are stored in a ‘database’. This is commonly organised into a series of data fields, usually one for each data type: a ‘clinical feature’ field would contain data such as ‘low mood’, ‘panic disorder’ etc.
It is more efficient to process data in numeric (e.g. 7123), or alphabetic and numeric (alphanumeric) form (e.g. a27e2), than to do so as text: hence the use of such codes. Numeric form also enables distinctions to be made between different uses of the same term: ‘liver’ as an organ and ‘liver’ as part of a diet may need to be distinguished in a record - giving each a distinctive numeric code enables this.
Codes, the terms they refer to and their meanings are held in a Data Dictionary or lexicon. The NHS, which has developed its own data dictionary, is moving to the use of a standard clinical lexicon, SNOMED CT (Clinical Terms; SNOMEDCT, 2007) which is attempting to include every term in the language of healthcare, each being given a unique code and meaning.
It appears to contain (on cursory examination) some of the key terms of relevance to psychology, such as ‘Wechsler Tests’ and ‘catastrophization’, providing the basis for coding the detail of psychological assessments and interventions. However, SNOMED would need to be searched in detail before it could be accepted as covering the key terminology of psychology services.
Such coding schemes are commonly structured in some way, with hierarchical ordering being used if the condition requires it. Diabetes’ is a higher level concept because it encompasses two sub-types. As an instance, a hypothetical diabetes code ‘d1236’ might have Type 1 and Type 2 diabetes given codes d1236.1 and d1236.2, respectively.
Clinical information system
Different commercial companies provide data management systems - computer programmes or software - to capture data to a database and then process the data to produce the information, the outputs or reports needed by clinicians, managers, commissioners, central government or those doing research.
A typical clinical information system might record client details, clinical features and data about process and outcome. It is essentially a data storage system with an interface between the user and the database. This interface allows the user to put data in, ask questions about the data, with the answers provided in on-screen or printed reports.
A clinician’s current list of clients or the ethnic mix or outcomes of the referrals seen over the previous year are instances of information contained in reports. The processes such as translation to codes and the production of standard reports are normally made to occur automatically, the user seeing only the end-product. These reports are for local use.
Data from the individual record will be transferred to the data warehouse databases from where they can be interrogated, either by the ‘privileged clinician’ or by others with special access. Researchers and those whose task it is to aggregate data to produce the reports required by policy-makers or those monitoring performance (called ‘secondary uses’) will be able to get access to anonymised data sets.
Impact
It is in this context that clinicians have to be prepared. NHS IT developments are proceeding and will have a direct impact on practice. Practitioners will be called upon to change and deal with some of the issues identified here. Openness with clients regarding records and information sharing will be required. Clinicians will be expected to know about and deal with client rights under the Data Protection Act, securing informed their consent and dealing with situations where this may not be possible.
Individual clinicians will also have to adapt to the changes required in moving from paper to electronic records, the demands of data entry as well as issues that will arise when managers have access to individual work diaries and rapidly available activity and outcome data, potentially enabling the monitoring of individual clinician performance.
Much is happening, with a lot of simultaneous developments, so that it is sometimes difficult to keep pace. It is also difficult for the non-specialist to sort and balance information emerging in the non-specialist media. Readers with an interest in what is happening (or not) in NHS IT can subscribe to free email services giving access to a helpful newsletters reporting developments from outside of the NHS and from within (see Key resources).
References
e-Health Insider Primary Care
Connecting for Health
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