Life on Marsland: Planning for the NHS Care Record

In his monthly column, former chief information officer Iain Marsland argues the NHS Care Records Service is like an iceberg. There’s more to it than meets the eye – and trusts need to understand that to get the most out of it. 



The ever imminent NHS Care Records Service (NHS CRS) is the best opportunity for English trusts to implement a functionally rich clinical information system that is capable of supporting all specialties.

Few trusts have succeeded in deploying an electronic patient record (EPR) in any depth, even though a few - such as Chelsea and Westminster, North Bristol (Southmead Hospital) and the national EPR pilots (Burton and Wirral) - have had some notable success. "Even the functions that sit above the water-line are breathtaking. They include results reporting, orders processing, clinical documentation, electronic prescribing and scheduling..."

In this column and next month’s, I’ll look at some of the lessons learned from those deployments as an aid to NHS CRS planning.

What you see is not all you get

NHS CRS is built like an iceberg. The part that is visible represents a set of benefits and associated management requirements. Underneath is an even greater raft of hidden capabilities, with another set of change management challenges and impacts on clinical services to consider before the full benefits can be realised.

Even the functions that sit above the water-line are breathtaking. They include results reporting, orders processing, clinical documentation, electronic prescribing and scheduling – all of which can be installed across all out-patient clinics, wards, theatres, diagnostics, therapies and specialties.

Then there are the hidden depths. In hospitals, they include electronic prescribing for out-patients and patients on discharge. These are similar to primary care prescribing; a script is written for the patient to take the drugs.

However, ward prescribing is actually an order to a clinician (normally a nurse) to administer a drug. Medication administration recording is therefore a key additional requirement, and one that delivers the additional benefit of providing a useful source of clinical information about how well patients took their drugs and whether they suffered any adverse reactions.

"Trusts will need to develop and exercise good clinical change management skills to make best use of the clinical decision support tools at each functional layer."
Underpinning these specific applications, which demand clearly-defined processes, are the decision support utilities that can be applied to all NHS CRS functions and support all clinician/patient encounters.

Trusts will need to develop and exercise good clinical change management skills to make best use of the clinical decision support tools at each functional layer. So let’s look at what decision support really means.

NHS CRS as a basis for decision support

NHS CRS can support clinical decision making in three ways:

1. Elective decision support means providing access to information services such as electronic medical libraries that clinicians can search at their convenience. Such services are increasing and now include mediated services, in which searches are undertaken in the background and push pre-defined information to the clinician.

2. Active decision support means detecting pre-defined clinical scenarios and “alerting” the clinician to them. These can be simple, low risk alerts such as picking up duplicate pathology requests or identifying additional requirements such as “check renal function before prescribing x”.

There can also be alerts for high risk, abnormal results, such as when a drug-drug or drug-allergy contraindication is identified. However, these need to be designed and deployed carefully as clinicians can become de-sensitised if too many alerts are embedded into the system.

3. Then there is passive decision support: a more subtle and more powerful tool. Passive decision support includes all forms of guidance that clinicians can choose, augment or ignore.

This could be as simple as single-discipline diagnostic order sets (such as liver function tests), multi-discipline diagnostics (such renal review pathology) or complex sets (such as emergency admission orders that initiate the diagnostics, drugs and therapies across a standard stay). "Trusts that understand and succeed in exploiting the hidden depths of NHS CRS will be in a strong position to deliver quality, safety and best value for money patient services."

Care pathways are the most complex form of passive decision support: a clinician is offered a pathway that sets out standard diagnostic and treatment protocols that are then followed by all professions involved in the care of the patient.

Power to the pathway

The power in the order sets, protocols and pathways is fourfold:

• Firstly, together with order communications, results reporting and electronic prescribing, they release clinicians from the huge administrative overhead of filling-in forms and chasing results, potentially saving 20-30 minutes per emergency admission.

• Secondly, they can only be constructed through dialogue with all of the professions involved in the pathway. Clinicians have reported that such dialogue enables them to work together much more closely in both front line specialty teams and extended teams that include pathologists, pharmacists and radiologists.

• Thirdly, care is standardised at the highest level, accredited by the lead consultant, and delivered to that level by even the most junior staff in the middle of the night.

• Finally, care is shared both across an extended team of clinicians and with patients themselves. Everybody knows the current state of the patient in relation to the pathway. All share responsibility for the total package of care. There are fewer hand-offs, resulting in much safer care for the patient and improved working practices throughout the team.

However, clinicians can still deliver care outside of a pathway, knowing that the clinical team will highlight and review exceptions in a positive and supportive manner.

Decision support needs careful planning and introduction. Trusts that understand and succeed in exploiting the hidden depths of NHS CRS will be in a strong position to deliver quality, safety and best value for money patient services. How? Next month we will look at deployment models for the new service.

About the author: Iain Marsland has been in the NHS for 34 years, most recently as chief information officer for Essex Strategic Health Authority and previously as director of IM&T for acute trusts in Brighton, Sussex and Bristol. He is now an independent consultant.