1. Matthew Swindells shared lessons learned from implementing electronic health records in the UK National Health Service. 2. Key lessons included remembering that the focus should be on improving healthcare by delivering information and ensuring local ownership, as well as being rigorous about standards and investing in infrastructure to enable new uses over time. 3. Implementation challenges included acknowledging public fears about privacy and security, redesigning processes to maximize clinical benefits, and confronting entrenched operational practices through brave leadership.

1. Portugal – 1st International meeting on the
electronic health record
** Experience from the UK **
26 November 2010
Matthew Swindells
Chair of the British Computer Society, Health
Visiting Professor, Surrey University School of Management
Vice President Global Consulting, Cerner Limited
Former CIO for the English National Health Service

2. Disclaimer and Declaration
• This is a personal view
• I am not representing policy on behalf of:
– The NHS or NHS Connecting for Health
– Any other government body UK or otherwise
– Cerner
– BCS
• I now work as Vice President for Cerner Limited, a
global health IT Supplier

3. An English Project
X
Scotland
X
Northern Ireland
X
Wales

4. Some highlights of the delivery
Secure
National
application
Encrypted indexes Data
servers
email standards
NHS
network Spine Choose GP to GP Technical
and SCR and Book transfer standards
4 prime Hospitals GPs Community and PACs SUS
contractors Mental Health
Later reduced to Two solutions Choice from an New products 100% coverage – Hub to
3 then 2 iSoft approved list developed saved more than standardise
Cerner forecast measurement
(replace IDX) and transactions

5. 1.
1998
1994
2002
Provide
Prescriptions
Service
IM&T Strategy for the NHS
Provide Bookings
Service
Pervasive national electronic infrastructure (N3)
Build Life-long
Provide Prescriptions
Health Record
Key:
Service
Service
Provide Bookings Service
Original Scope
Build Life-long Health
Record Service
Commissioning
Patient Choice
Digital Imaging
Additional Scope
Pervasive national electronic infrastructure (N3)
Secondary Uses Service
Payment by Results
NHS Email System
Policy and medical practice changes are a fact of life
Transfer of records
between GPs
Quality Management
Analysis System
NHS Numbers for Babies
Healthcare is never a stable environment
Plurality of provision
Bowel Cancer Screening

6. 2. Remember it’s about improving healthcare
Focus on delivering information and improvement not technology
Challenge – Clinical Knowledge-Processing Burden
“Current medical
practice relies
heavily on the Knowledge processing requirement
unaided mind to
recall a great
amount of
detailed
knowledge – a
This gap
process which, to
injures patients
the detriment of
all stakeholders, Knowledge processing capacity
has repeatedly
been shown
unreliable”
Crane and Raymond
The Permanente
Years ago Today
A study published in British Medical Journal in
Journal
Winter 2003 Volume 7 No.1
Kaiser Permanente Institute for Health
2004 concluded that:
Policy
• 1 in 16 hospital admissions are the result of an
adverse drug reaction – 76% avoidable.
• This equates to 4% of hospital bed capacity At any
one time 7 x 800 bed hospitals are occupied by
patients admitted with ADRs. Cost = £466m
annually –
• Patient harm and £354m expenditure avoidable
by putting in place e-prescribing ?
[1] Pirmohamed, M. et al: Adverse drug reactions as a cause of admission to
hospital: prospective analysis of 18,820 patients: BMJ 2004; 329: 15-19

7. 3. Acknowledge and confront public fears
Make the benefits argument - the media doesn’t help!
NHS porters and cleaners can
snoop on your medical records
Daily Mail 26-Mar-2010
'Big brother' health database
Daily Mail 11-Oct-2010

8. 4. Ensure local ownership and build capacity
You can’t nationalise responsibility

9. 5. Deliver clinical functionality early
What’s in it for the clinical staff?

10. 6. Redesign and improve the service
Computerisation of poor process solves nothing

11. 7. Be rigorous about standards
Data, integration and semantics are all important
• Terminology: SNOMED CT http://www.ihtsdo.org/ What is the date Wednesday next week?
• Drug Database: dm+d http://www.dmd.nhs.uk/
• https://www.uktcregistration.nss.cfh.nhs.uk/trud/ • It will be the 1st of December 2010
• Professional Record Keeping: • UK 1/12/10
http://www.rcplondon.ac.uk/clinical-standards/hiu/medical-records • US 12/1/10
• Professionalism: UKCHIP http:www.ukchip.org.uk • Sweden 10/12/1
• Definitions: i.e. ‘Allergy’ and ‘Current Medication’
• Messaging: HL7 v3 http://hl7.org
• So in health it’s 01-Dec-2010
• Logical Architecture / Archetypes: and that’s final !
http://www.connectingforhealth.nhs.uk/systemsandservices/data/l
ra
• Knowledge and Knowledge Authorship: • By doing this I just reduced the number
of errors it’s possible to make for 12 days
• Device Interoperability: www.continuaalliance.org a month.
• User interface design: www.cui.nhs.uk
• Open Health tools: www.openhealthtools.org
How many times do these need to be invented globally ?
Adopt what’s already there and be rigorous about enforcing it.
No competition on standards!

12. 8. Invest in the infrastructure
You’ll think of new things to use it for
Secure
National
application
Encrypted indexes Data
servers
email standards
NHS
network Spine Choose GP to GP Technical
and SCR and Book transfer standards
Thousands of NHS medical records lost
Daily Telegraph
Central
Expertise

13. 9. Use more than one vendor
Competition future proofs your investment

14. 10. Be Brave
“Culture eats strategy for breakfast”
Some times you feel as if you are fighting 100 years of
operational practice on your own!

15. Ten lessons
1. Healthcare is never a stable 6. Redesign and improve the service
environment • Computerisation of poor process
• Policy and medical practice changes solves nothing
are a fact of life 7. Be rigorous about standards
2. Remember it’s about improving • Data, integration and semantics are
healthcare all important
• Focus on delivering information and 8. Invest in the infrastructure
improvement not technology
• You’ll think of new things to use it for
3. Acknowledge public fears
9. Use more than one vendor
• Make the benefits argument
4. Ensure local ownership and build • Competition future proofs your
investment
capacity
• You can’t nationalise responsibility 10. Be brave
5. Deliver clinical functionality early • This is really hard. Change is hard.
The technology is difficult. Can you
• What’s in it for the clinical staff?
imagine a health service where we
don’t confront this challenge

16. ** Experience from the UK **
Questions
Matthew Swindells
Chair of the British Computer Society, Health
Visiting Professor, Surrey University School of Management
Vice President Global Consulting, Cerner Limited
Former CIO for the English National Health Service
matthew.swindells@cerner.com
+44 7961 557556