Life on Marsland visits the Irish electronic health record
Ireland is looking at the options for creating an electronic health record. Iain Marsland sets out the options and what the country might learn from England’s National Programme for IT in the NHS.
The Irish government is the latest to consider electronic health records (EHRs) as a way of improving patient safety, healthcare effectiveness and efficiency and to support patient empowerment.
Healthcare in Ireland is a mix of private and state funded. A government department, the Health Service Executive (HSE), has responsibility for health information and data quality.
It is also responsible for setting standards for both public healthcare providers and other service providers. It does this through an executive agency, the Health Information and Quality Authority (HIQA).
HIQA has been looking at EHRs across the world and evaluating different models including:
• A simple national index that can be referenced by all systems / users as required
• An index that is re-broadcast to local systems
• A national primary index (along the lines of the Summary Care Record being developed in England) that is referred to in real time by local systems
• As above, plus key health indicators such as allergies and recent drugs
• As above, plus healthcare activity and summary health data (such as discharge summaries)
• As above, with all patient clinical data
• As above, plus personal (self managed) data
• A virtual EHR derived from linking local electronic patient record (EPR) systems and pulling in data in real-time.
“The architecture of the National Programme for IT in the NHS was founded upon the need to support a gentleman from Newcastle who became ill whilst on holiday in Brighton. You might think that if somebody had suggested to that gentleman that he should holiday in Whitley Bay that year, then the NHS could have saved £12bn.”
In Canada, for example, EHRs are set up on a regional basis. However, this may be unnecessary for a country the size of Ireland; with a population of just 4 million.
Other countries actively embracing EHRs include Finland, the Netherlands, Sweden, Australia and Turkey. Most are pursuing a database of key health issues. Australia has added self-managed personal data as well.
Standards matter
HIQA appears to have discounted a national EHR with transactional functions such as scheduling and prescribing; understanding that these functions are best delivered by local EPR systems. This seems sensible to me, and probably stems from a quick glance at the speed of delivery of systems across the Irish Sea in England.
HIQA will also have a focus on standards. All the countries involved with EHRs utilise the messaging standard HL7 v3, with the exception of Sweden, which prefers CEN 13606.
The CEN 13606 approach is to represent the reference model as a set of Unified Modelling Language (UML) diagrams. The outcome is a hierarchical model, composed of a number of classes, reflecting the hierarchical nature of real health records. I, for one, am very grateful that there are people who understand and are energised by such issues.
Lessons from England
HIQA is determined to take a long look at available options and to learn lessons from countries already progressing EHRs. So what can we offer?
Well, the value of an EHR depends on the how the EHR is populated, the source data, how the data will subsequently be used and the frequency or volume of those transactions.
Although the UK has a National Health Service, healthcare tends to be provided locally. In fact, in most cases, healthcare activity is inversely proportional to distance from home. This means that anyone considering an investment in EHR’s should consider whether the cost is proportional to the volume of activity.
The architecture of the National Programme for IT in the NHS was founded upon the need to support a gentleman from Newcastle who became ill whilst on holiday in Brighton. You might think that if somebody had suggested to that gentleman that he should holiday in Whitley Bay that year, then the NHS could have saved £12bn.
With the exception of primary care data, where systems are in place and sufficiently mature, the source data for EHRs is currently very sparse. EHRs depend on local EPRs to feed them. Until these complex systems are in place throughout local health organisations, and especially in secondary care, then the EHR will remain poorly populated.
However, linking local systems around a common patient number – still to be introduced into Ireland – and a standard nomenclature will enable multi-provider care pathways, especially for patients with long term conditions, and better prescribing.
In previous columns, I have noted that clinicians still have a healthy distrust of clinical opinion recorded by other professions and - in some cases - by clinicians in their own profession. This limits the value of EHR to objective data such as drugs and diagnostic results.
I suspect that, if asked, many involved with the English National Programme for IT in the NHS would be more than willing and able to offer further opinion.
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, advising trusts on how to procure and implement electronic patient record systems, among other issues. Iain writes every four weeks for the NHS Resource Centre.