A bloody mess: Britain's health information network

As the United States seeks to implement its own health network by 2014, Britain's experience is providing significant lessons, driving home the point that assembling a national network is a complicated, gargantuan task, even in a country where, presumably, under a single-payer system, it should be easier.

That's judging by the rancor inspired by the $11 billion plan, under way by the National Health Service. And who could blame physicians and others for getting upset, what with only a small portion -- a scheduling program (or programme, as they'd say in Britain) -- even on the verge of implementation, a year behind schedule?

"Huge waste of money and confidentiality likely to be compromised. ... The biggest government I.T. disaster yet?" wrote an anonymous British general practitioner in response to a survey released last January by Medix UK. That survey found physicians becoming more skeptical about the cost of the program and how it's being implemented, with 57% of the 1,329 respondents saying the project was not a good use of NHS' resources.

"Chaotic, slow and confused implementation," another doctor wrote.

"My overall concerns are that it's a massive program with the right objectives, but it's costing a fortune and it's being totally mismanaged," Dr. Nigel de Kare Silver, a general practitioner in London, told the British publication e-Health Insider late last year. He also told the BBC that the government system, as now proposed, would force him to dump the electronic medical record system he just bought.

One lesson the United States has learned is that it's better to build a network from doctors' offices on up, rather than a top-down, government-mandated approach. The U.S. plan calls for doctors to link systems through regional health information organizations, which then would become linked to a national system.

To implement Britain's network, the NHS Connecting for Health, an agency of the Dept. of Health, awarded $11 billion in contracts to four vendor consortiums to automate five regions across England. The consortia, led by Computer Sciences Corp., BT Group and Fujitsu Ltd., have contracts for one region each, while Accenture has contracts for two. As of Jan. 30, NHS had dished out $960 million to the vendors, who are paid only when they deliver systems that work.

So far, implementation has been rocky because of several factors. These include aggressive timetables for projects, vendors repeatedly missing deadlines, general practitioners complaining that the government did not consult them adequately about the system and political meddling.

In November 2005, the government admitted that a key component of the project, an online appointment system called Choose and Book, wouldn't be fully operational until the end of 2006, a year behind schedule. That unleashed increasingly scathing questions and skepticism from the media and members of Parliament, apparently creating a bunker mentality that has made it difficult to measure the project's progress. NHS and Richard Granger, director general of information technology at NHS in charge of the project, have not responded to AMNews' requests for an interview. In past published reports, vendors generally have limited themselves to acknowledging the project is "complicated."

"The vendors [and consultants] I spoke to said, 'Peter, we cannot tell you how it's going; if we say one bad word against the program, we will be squeezed out,' " said C. Peter Waegemann, CEO of the Medical Records Institute, Newton, Mass., after he returned from London.

Still, most observers don't expect the project to end in disaster. "It'd be very wrong to assume that this program is going to crumble," said Jonathan Edwards, a research director in the London office of Gartner Inc., a technology consulting firm. "It has very strong backing from the government, and there is no way this program is going to be allowed to fail."

One lesson about implementing networks, judging by Britain's experience, appears to be universal: If you don't involve physicians early, you won't get them later.

Getting physicians onboard

It appears that NHS failed to adequately educate doctors about the new system. For example, 56% of physicians said they had little or no information about the program, 6% had never heard of it and only 4% said they had a lot of information about the project, Medix's survey said.

"I have been aware of the National Program for I.T. for a long time, but there has been no significant communication or support from the primary care trust," was one doctor's response to the survey. Primary care trusts are local management organizations whose function includes getting health and social care systems working together to the benefit of patients. There are more than 300 PCTs in England.

While many doctors don't feel they have enough information, the survey offered encouragement to NHS, including a finding that 59% of general practitioners and 66% of other doctors believed the national network will improve clinical care in the long term.

For any national networking project to be successful, the bottom line is that working physicians must be involved at its earliest stages, said Dr. Richard Vautrey, a member of the British Medical Assn.'s General Practitioners' Committee, which represents GPs in the United Kingdom. A big problem was NHS and the vendors negotiated contracts "very much behind closed doors," he said.

NHS included doctors in the planning and design of its program, but those doctors were "technical experts" rather than grassroots physicians. The latter "probably don't have a great understanding necessarily of I.T. but actually use it in their everyday working life, know what they want out of I.T., know what currently works and what would be workable," Dr. Vautrey said. NHS appears to have learned that lesson, he said, explaining that the agency has actively engaged and sought input from doctors over the past year or two.

But had NHS done that sooner, it might have been able to avoid committing blunders that have eroded physician support. One of those mistakes was implementing the online appointment system doctors have blasted as "a national scandal," "a joke" or "crazy" in part because it is slow, unreliable and cumbersome.

In fairness to NHS, however, doctors should blame politicians for foisting the much-maligned Choose and Book on them, said Tola Sargeant, senior analyst at Ovum, a technology consultancy in London.

Initially, NHS awarded a contract that called only for general practitioners to book hospital appointments electronically for patients, she said. But after the contract was awarded, politicians mandated that patients be given a choice of four hospitals. That moved the goalpost for NHS midway through the process, making the integration of physician and hospital systems even more complex than it already was, she said. The mandate also meant more work for physicians. Now, they had to talk patients through the hospital choices, whereas before, they referred patients to a local hospital, which later contacted patients with an appointment date.

"The actual process of sitting down with patients and talking them through the various options of hospitals, saying which one you think they should go to and helping them make that decision ... is quite time-consuming," Sargeant said. "There's been reluctance from GPs to actually do that."

Because of that, few doctors are using Choose and Book, which is up and running in some areas. "Normally in the UK, we allow maybe 10 to 12 minutes per patient," said Dr. Azeem Majeed, a general practitioner and professor of primary care at the Imperial College of London. "In theory, Choose and Book can take two minutes, but in practice it takes five to 10 minutes because it can be so slow."

Had NHS asked, Dr. Majeed would have told the agency to make implementing the electronic transfer of patient records from one practice to another a top priority rather than the appointment system. He and his colleagues can't wait to have that capability, because they now must print out patient records on paper, and staff at another doctor's office has to re-enter that information manually in its EMR when patients change practices.

Deliver solutions doctors want

England's experience with Choose and Book underscores the need to avoid politicizing projects and deliver systems physicians will find useful, Edwards said. "The program in England and programs elsewhere suffer from an excessive amount of involvement from [politicians] who are eager to impress voters ... and therefore make decisions and start initiatives that look and sound good to the electorate, but don't have any [practical] basis in terms of what the health system really needs," he said.

Another lesson is that doctors must be able to choose what EMR system they implement in their office. NHS upset physicians when it limited their choice of EMRs to the two vendors that had contracts within their region, Dr. Vautrey said.

The issue also was exacerbated when Egton Medical Information Systems Ltd. was excluded from the contracting process, Dr. Vautrey said. The company's EMR is used by more than half of the country's general practitioners, who worried that when they were ready to upgrade their systems, they would have to switch to a system that potentially could be worse than the one they used. But EMIS also is to blame for the fiasco, because it didn't want to be bound by the government's contracting requirements, he said.

Still, the upshot is that general practitioners might have the opportunity to choose whatever system they want, because the contract they negotiated in 2004 with NHS allows them to have a greater choice of systems. (Physicians in Britain are independent contractors, not government employees.) Since then, the agency has talked about allowing doctors to pick any vendor whose system is accredited by it or has a contract with any of the four major vendors, Dr. Vautrey said. The British Medical Assn. expects the government to make an announcement soon.

"I think many, many GPs are very cynical about the project," he said. "I think that one of the problems for GPs is that they currently have systems that work well for them, and they feel that anything that is being proposed nationally actually may be worse than what they've currently got."