In defence of single clinical record systems

Last month, the Department of Health confirmed that it was ditching its plans for a single clinical record system for England. Instead, IT policy will be devolved to local NHS organisations. On the face of it, this new emphasis on local flexibility may sound appealing but we should not forget the potential hazards that come with fragmented IT.

The original plan would in essence have created a single set of medical records for all patients, to which patients could grant access to clinicians working in any part of the NHS. The alternative we are now facing will be a separate, partial medical record held at each hospital and clinic that a patient ever attends.

This fragmentation will mean that hospital clinicians will not be able to see the full picture of the care being provided to their patients in the community, nor will primary care staff be kept fully abreast of the care their patients receive in hospital. Duplicated tests and conflicting treatments are likely to ensue.

Additional problems, however, are likely to occur when clinicians or patients move from one NHS organisation to another.

At the moment, clinical record-keeping in almost all NHS hospitals is still paper-based. Doctors and nurses track their patients’ progress using handwritten notes, and IT is mainly used for peripheral tasks such as ordering tests and viewing scans. Under this arrangement, staff can begin work straight away when they change jobs. However, when hospitals start using IT for the entire patient record, things may become more problematic.

In the airline industry, pilots who qualified on one type of aircraft must spend several months re-training before they can fly a different manufacturer’s plane safely. Aviation is an extreme example, but do we really want doctors and nurses using electronic record systems on which they are not fully competent?

The cost of re-training clinicians every time they changed to a hospital with a different IT system would be daunting. But the alternative is to restrict the hospital labour pool and to reduce the training opportunities for junior staff who currently rotate between hospitals.

A more serious problem with fragmented IT may occur when patients are transferred from one hospital to another. Currently, a photocopy of the notes tends to accompany patients to a new unit. While this is not a particularly elegant solution, the analogous ‘workarounds’ for hospitals with incompatible fully-electronic systems could become even messier.

The optimists will tell you that common standards will allow patients’ notes to be ‘synced’ across different systems used by hospitals and clinics. They may well be right. All I know is that when I synchronise my electronic calendar across different devices, things work perfectly a good 99% of the time but just occasionally a glitch occurs. Suddenly, a recurring appointment will disappear from my schedule, or the details of a meeting request will become corrupted. With calendars, this is obviously not a matter of life and death — but in health care it genuinely could be, on occasion.

The Department of Health has said that delivering a single care record is simply too difficult for England. However, other countries are managing it. Look at Jordan, for example, where an open-source IT system is being implemented across all hospitals and primary care clinics.

Within England, too, we have some world-leading examples of national health IT systems. For example, the Hospital Episode Statistics database collates information about patient care across all NHS hospitals and is the envy of researchers the world over. And more recently, the Health Protection Agency has implemented a single care record system, HPZone, covering the whole of England, which several other European countries are now adopting.

So, before we finally ditch the aspiration of a single care record for the NHS in England, it might be worth reflecting one last time on the true costs and dangers of fragmented health IT.

This article has also been published on the The Guardian Healthcare Network website.