Background

10. NHS organisations have long made use of a wide range of IT systems. However, levels of computerisation have generally varied considerably between, and often within, organisations and tiers of care. As a broad outline, the following characteristics have been typical:

• General practitioners have had the highest level of computerisation with the vast majority of surgeries using IT systems both for administrative and clinical purposes. Most practices have stored some patient information electronically, and many have dispensed with paper systems altogether after scanning old paper notes into new electronic systems. The new GMS contract, introduced in 2004, consolidated the high level of IT usage in general practice by requiring payments and performance assessment to be processed electronically.[3]
• In hospitals, the level of computerisation has varied widely but has been consistently lower than in general practice. All NHS hospitals have used basic Patient Administration Systems (PAS) for a number of years for administrative purposes such as scheduling, recording admissions and discharges, and storing patient demographic and basic diagnosis information. In some clinical areas, such as theatres and pathology, more sophisticated systems have often been used for both administrative and clinical purposes. However, the use of more complex systems capable of recording all aspects of clinical care has been extremely rare, and the overwhelming majority of patient records have been stored in often voluminous paper notes.[4] The lack of unifying standards and a piecemeal approach to procurement has meant that IT systems in different departments within a single hospital have often been unable to communicate with each other.
• Amongst community and mental health care providers, levels of IT use have been the lowest of all. Many such organisations have not used computers even for administrative purposes and have stored all patient records on paper.[5]
• More complex systems have been developed in some parts of the country across clinical networks with responsibility for a particular patient group. For example, shared databases and other IT systems have been used at local level by cancer, diabetes and renal networks.

11. In general NHS IT systems have been characterised by an inability to share information between different organisations, between primary and secondary care, and often between different parts of the same organisation. The situation was likened by one witness to a series of "electronic islands" with little ability to communicate.[6]

12. In 1998, the Government launched an NHS information strategy, Information for Health. The strategy was intended to run until 2005 but was superseded in 2002 by NPfIT. Information for Health's goals included:

• The creation of an electronic health record, containing "lifelong core clinical information" for each NHS patient, by 2005, developed initially by linking local primary care systems; and
• Establishing "level 3" electronic patient record systems in all hospitals by 2005 (to include electronic ordering, reporting, prescribing and care management).[7]

The National Programme for Information Technology

13. In June 2002, the Department of Health published Delivering 21^st century IT support for the NHS: national strategic programme, effectively the blueprint for the National Programme for Information Technology (NPfIT). The strategy restated the importance of the goals set out in Information for Health but acknowledged that progress had been hampered by lack of protected funding, lack of central direction, poor value for money and a shortage of network capacity.[8]

14. Delivering 21^st Century IT proposed to address these problems through a more centralised, national approach to NHS IT, linked to the ambitious goals and generous funding increases embodied in the 2000 NHS Plan.[9] The document stated:

The core of our strategy is to take greater central control over the specification, procurement, resource management, performance management and delivery of the information and IT agenda. We will improve the leadership and direction given to IT, and combine it with national and local implementation that are based on ruthless standardisation.[10]

WHAT NPFIT AIMS TO DELIVER

15. The initial aims of the project were to establish three main systems:

• An Electronic Transfer of Prescription service (ETP);
• An electronic appointment booking service (subsequently expanded in scope to become Choose and Book); and
• The NHS Care Records Service (NCRS), including a detailed electronic patient record to be shared by local organisations and a summary record, available nationally.[11]

16. The programme's initial aims also included major upgrades to existing software and network infrastructures, including the following:

• The creation of a private broadband network to link all NHS organisations to the national system, known as the New National Network for the NHS (N3);
• The development of a National Data Spine to store information centrally, to link local and national IT systems and to host national systems such as the Summary Care Record; and
• The widespread installation, replacement or upgrading of basic computer systems across the NHS, including PAS software for hospital and community providers and new or upgraded systems for GPs.

17. In order to achieve these goals, the Department of Health agreed a number of contracts with a range of private suppliers in 2003 and 2004. The main contracts are shown in the table below:

Service	Scope	What it does	Contractor	Date Agreed	Value (£m)
New National Network for the NHS (N3)	National	Fast and reliable network to enable communication within and between NHS organisations. The foundation of the rest of the NPfIT project.	British Telecom	Feb 2004	530
National Data Spine	National	Database which holds patient demographic information, national electronic patient record (Summary Care Record) and enables communication between national and local NPfIT systems.	British Telecom	Dec 2003	620
Choose and Book	National	Links GP and hospital systems to allow electronic booking of appointments.	Atos Origin	Oct 2003	64.5
NHSmail	National	NHS-wide e-mail service.	Cable & Wireless	July 2004	50-90
Local Service Provider - North East	Regional	Provision of NHS Care Records Service, new Patient Administration Systems and prescribing (ETP) systems across the region.	Computer Sciences Corporation (Accenture until Sep 2006)	Dec 2003	1,100
Local Service Provider - London	Regional	Provision of NHS Care Records Service, new Patient Administration Systems and prescribing (ETP) systems across the region.	British Telecom	Dec 2003	996
Local Service Provider - Eastern and East Midlands	Regional	Provision of NHS Care Records Service, new Patient Administration Systems and prescribing (ETP) systems across the region.	Computer Sciences Corporation (Accenture until Sep 2006)	Dec 2003	934
Local Service Provider - North West and West Midlands	Regional	Provision of NHS Care Records Service, new Patient Administration Systems and prescribing (ETP) systems across the region.	Computer Sciences Corporation	Dec 2003	973
Local Service Provider - South	Regional	Provision of NHS Care Records Service, new Patient Administration Systems and prescribing (ETP) systems across the region.	Fujitsu	Jan 2004	996

Table 1: Main NPfIT contracts

Source: National Audit Office

18. Since 2002, the scope of NPfIT has increased as a number of additional services have been added to the original specification. These include:

• Digital capture and storage of X-rays and other diagnostic results through the installation of Picture Archiving and Communications Services (PACS) in acute hospitals;
• Automation of assessment of GP practice performance against the new GP contract using the Quality Management Analysis System (QMAS); and
• A system (known as GP2GP) for moving patients' GP records instantly from one practice to another when a patient switches practice.

HOW THE PROGRAMME IS ORGANISED

19. In contrast with previous NHS IT strategies, NPfIT involves the procurement of new systems and services at a national level rather than by individual NHS organisations. In 2005, responsibility for NPfIT was transferred from the Department of Health to an arms-length body, NHS Connecting for Health. Thus all of the contracts listed in table 1 were agreed on behalf of the NHS by the Department of Health and are now held and managed by Connecting for Health. The majority of new systems will be installed in local NHS organisations, but suppliers are answerable to Connecting for Health, a national organisation. Connecting for Health is currently transferring some responsibility for contract management to the 10 regional Strategic Health Authorities (SHAs) through the NPfIT Local Ownership Programme (NLOP), which we discuss in Chapter 4.

20. Since its inception, the project has been headed by Richard Granger, inaugural Director General for IT in the NHS. Mr Granger announced in June 2007 that he would leave his post by the end of the year.[12]

21. Department of Health and Connecting for Health officials praised the centralised organisation of the programme, arguing that the introduction of national-level procurement in 2002 had led to a step change in progress on the delivery of new IT systems to the NHS. They pointed out that the centralised approach had led to:

• Better value for money because of national procurement: officials argued that local procurement of systems had generally proved unaffordable in the past;[13]
• Much more consistent development of IT across the NHS, in contrast with the previous "electronic islands";[14]
• Greater potential for interoperability between systems than if a more localised approach had been taken.[15]

22. Defending the centralised approach to the programme, Richard Granger was especially critical of progress prior to the inception of NPfIT:

…the progress that had been made was lamentable—and yet at very significant cost of about a billion pounds a year at 2002. The revisionists are busy at work now trying to make out the progress that had been achieved before 2002 was extremely good and has somehow been retarded by the introduction of national systems; but the evidence does not substantiate that viewpoint.[16]

23. As table 1 demonstrates, some of the main NPfIT contracts cover services to be provided nationally across the whole of the NHS, such as the N3 network and the National Data Spine (which includes the Summary Care Record). Contracts are also in place for the provision of services across regional areas. For this purpose, the NHS was divided into five geographical 'clusters', for each of which a Local Service Provider (LSP) contract was agreed. LSPs were contracted to provide a wide range of services to organisations across their 'cluster', including new PAS systems and the other services which will contribute to the Detailed Care Record. The five LSP contracts made up 80% of the value of the initial contracts (around £5 billion of the total value of £6.3 billion). The five 'clusters' and their LSPs are shown below:

Figure 1: The 5 regional NPfIT 'clusters'

24. The five LSP contracts were originally awarded to four different suppliers, with Accenture holding two of the five contracts. However, Accenture withdrew from the programme in September 2006 and its two LSP contracts were transferred to Computer Sciences Corporation (CSC), one of the existing LSPs.[17] Thus CSC now holds three of the five LSP contracts with the others continuing to be held by Fujitsu and BT. BT also holds the two major contracts for supplying services at a national level, those for the N3 network and the National Data Spine.

25. LSPs have subcontracted some areas of their work to smaller, more specialised companies. In particular, the development of new PAS software for hospitals and community care providers has generally been outsourced. In the three clusters now under CSC, the Lorenzo PAS system is being provided by iSoft, a UK software firm.[18] In the London and Southern clusters, a Common Solution Project was initially formed between BT and Fujitsu to procure PAS systems from the US software supplier IDX. However, the partnership was subsequently dissolved and both LSPs subsequently switched from IDX to another US firm, Cerner, as their main PAS system supplier.[19] Cerner will supply the Millennium PAS system.[20]

26. The current suppliers for new hospital PAS software are shown in the table below:

Cluster	Local Service Provider	PAS system	PAS system supplier
London	BT	Millennium	Cerner (IDX until July 2006)
Southern	Fujitsu	Millennium	Cerner (IDX until April 2005)
Eastern	CSC	Lorenzo	iSoft
North East	CSC	Lorenzo	iSoft
North West & West Midlands	CSC	Lorenzo	iSoft

Table 2: Hospital PAS suppliers by cluster

Source: National Audit Office

PROGRESS TO DATE

27. Assessments of NPfIT's overall progress to date have varied widely. The Department of Health's evidence submission provided an upbeat assessment of progress:

[NPfIT] is already providing essential services to support patient care and the smooth running of the NHS, without which it could not now properly function. Installation of a modern, high speed, secure infrastructure and national network [N3] has been completed ahead of schedule and is daily supporting millions of business transactions in the NHS…Widespread coverage of Community Patient Administration Systems has been achieved where nothing existed before. Over half of hospitals now have digital x rays and scans.[21]

28. Richard Granger offered the Committee a range of statistics to demonstrate the scale of progress:

We now have 19,000 places connected up, so we have one of the biggest virtual private networks on the planet and people take that for granted. We are now computerising, to deliver prescriptions safely, 200 GP practices a week with the relevant software. We typically move 120,000 prescriptions electronically now on any given day. About every 10 seconds a patient gets a booking completed electronically.[22]

29. Evidence from suppliers was equally positive about progress. BT, both the supplier of the main national systems and the LSP for London, provided a clear timetable for completion of their contracted elements of the programme:

The foundations of the NPfIT system provided by BT are now built, operating and secure. Culturally integrating these systems so they become second nature for NHS staff is well underway. Over the next five years, the goal is to complete this programme.[23]

30. A report by the National Audit Office (NAO), published in June 2006, however, was notably less bullish. While commending the "substantial progress" achieved by the programme, the NAO also acknowledged that implementation "continues to present significant challenges".[24] In particular, the NAO report highlighted:

• delays of ten months to the delivery of the National Data Spine and around two years to the launch of the Summary Care Record, both the responsibility of BT;[25] and
• delays of between one and two years to the delivery of systems by LSPs.[26] The Department of Health has acknowledged that the installation of new hospital PAS systems, one of the key responsibilities of the LSPs, is now "up to two years behind schedule".[27]

31. The subsequent report from the Public Accounts Committee (PAC), published in March 2007, expressed further doubts. In particular, the PAC highlighted:

• Two-year delays to both the national and local elements of the NHS Care Records Service, pointing out that "no firm implementation dates exist" for these elements of the programme;
• The failure to quantify the benefits which the programme will deliver;
• A lack of capacity amongst suppliers, exacerbated by the withdrawal of Accenture, and an over-reliance on two main software suppliers, Cerner and iSoft, for delivery of key elements of the programme;
• The lack of effective communication with clinicians by NPfIT's leaders and failure to clarify the roles of local NHS organisations in the delivery of the programme; and
• A narrow focus on the delivery of new systems rather than the "broader process of business change" required to maximise benefits.[28]

The PAC concluded that,

At the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period.[29]

32. Estimates of the likely overall costs of the programme have also varied substantially. As shown in table 1, the cost to the NHS of the main initial contracts will be £6.3 billion over the 10 years of the contract. However, the NAO estimated in its report that the total cost of implementation, including expenditure by local organisations, will be £12.4 billion.[30] In its response to the Health Committee's 2006/7 Public Expenditure Questionnaire, the Department of Health estimated the total net cost of NPfIT at £7.5 billion, after accounting for an estimated £4.2 billion of cost savings as a result of the national programme.[31]

The NHS Care Records Service

33. At the heart of NPfIT is the NHS Care Records Service (NCRS), a set of projects which eventually aim to provide detailed electronic patient records across the NHS which can be shared between different clinicians, organisations and tiers of care. The majority of the expenditure on the programme, including the creation of the National Data Spine and the replacement of local PAS systems across the NHS, is in support of the NCRS. As the PAC put it, the NCRS is "central to obtaining the benefits of the programme".[32] The Department of Health described NCRS as the "cornerstone" of NPfIT.[33]

WHAT NHS CARE RECORDS SERVICE AIMS TO DELIVER

34. The NCRS will be made up of a group of systems with distinct functions and purposes. These are:

• The Personal Demographics Service (PDS), an application supported by the National Data Spine, which is already in widespread use. [34] The PDS contains basic demographic details about every NHS patient including name, address, date of birth, NHS number and current GP.[35]
• The Summary Care Record (SCR), which is also supported by the Spine and is currently being piloted in the Northwest. The SCR will be a high-level record of key clinical information including allergies, prescriptions, summary medical history, operations and procedures. An SCR will be created for every NHS patient, although patients can choose to opt out, and will be potentially available throughout England. We examine the SCR in Chapter 3.[36]
• Local record systems, on which comprehensive patient records will continue to be stored in hospitals, GP surgeries and other organisations. Many of these systems will be replaced or upgraded as part of NPfIT and paper systems will increasingly be replaced by electronic systems. In hospitals, for example, new PAS systems will be installed to fulfil a range of largely administrative functions, followed by more detailed clinical systems which will in time reduce reliance on paper records. Local systems will feed a subset of information into both the Summary Care Record and Detailed Care Record systems, and as such will remain the foundation of the records service.[37]
• The Detailed Care Record (DCR), which will be created by combining information from local systems and will hold significantly more detailed clinical information than the SCR. It will be created by linking or sharing information from the systems used by local providers (GPs, hospitals, community providers and others) to produce a single, detailed electronic record which can be shared across the local health economy. This means that some patients may have more than one DCR if they have been treated at organisations in different parts of the country. The DCR is likely to contain details of past and current conditions, assessments, diagnoses, treatments and care plans.[38] The systems which will make up the DCR are being provided by LSPs.[39] We look at the DCR in Chapter 4.
• The Secondary Uses Service (SUS), which will collect, manage and analyse electronic health data from a range of sources, eventually including the new NCRS systems. The SUS will provide a single point of access to aggregated data for purposes including management, commissioning, clinical audit and research. An early version of the SUS is already in operation, using datasets such as Hospital Episode Statistics to support management functions such as Payment by Results.[40] However, the development of the NCRS will vastly increase the depth and breadth of data available through the SUS by allowing clinical data to be obtained directly from operational EPR systems.[41]

PROGRESS TO DATE

35. The delivery of the NCRS systems relies on the success of a number of related NPfIT projects, particularly the upgrades to network and software infrastructure. For example, the new NCRS systems will be underpinned by a number of national applications including the N3 network, the National Data Spine and the Personal Demographics Service. The DCR can only begin to take shape once the mass upgrades to hospital and community PAS systems have been completed, a task which is proving complex and time-consuming.[42] Similarly, the benefits of the SUS can only be maximised once the other NCRS systems are in place and operating successfully. Although their functions are distinct, the NCRS systems are reliant on each other, and on other NPfIT projects, both for their delivery and for their ultimate usefulness.

36. As stated above, the PDS and SUS are now operational, although the range of data available to the SUS remains limited. Following a two-year delay and intervention from a Ministerial Task Force, the SCR is now being piloted at GP practices in the Bolton area, although it is not clear exactly when the system will be made available throughout England. The timetable for delivering the DCR remains unclear, largely because of delays to the new Millennium and Lorenzo hospital PAS systems, as well as the replacement of IDX with Cerner as the main software supplier to the London and Southern clusters. An early version of Cerner's Millennium system has now been deployed at some hospitals, but iSoft's Lorenzo system is yet to be deployed anywhere. Until such basic systems are in place, the development of the shared DCR cannot begin. More detail about progress on the main NCRS systems is provided in Chapters 3, 4 and 5 below.

INTERNATIONAL COMPARISONS

37. The NCRS is one of a number of EPR systems being implemented across the developed world. During our inquiry, we visited three other countries currently undertaking major EPR projects:

• Canada, where efforts to create a Private Lifetime Record for each citizen are being co-ordinated by Canada Health Infoway (CHI). CHI aims to establish an electronic record for 50% of Canadian citizens by the end of 2009;[43]
• France, where legislation to create a Dossier Médicale Personnel (DMP) was passed in June 2004. The DMP will contain a range of health information which can be viewed online. Access will be controlled by patients who will legally own their record. The DMP system is being implemented between 2006 and 2010 at an estimated cost of €1.2-1.5 billion;[44] and
• The United States, where a number of integrated electronic records systems already exist, for example the VistA system used by the Veterans Affairs Administration. In 2004, President Bush set out the goal of establishing electronic health records for "most" US citizens by 2014.[45]

38. The situation in these three countries is similar in many ways to that in England. In general:

• There are low rates of IT use and investment in healthcare compared with other sectors of the economy; indeed, more information about patients is generally stored electronically in England, especially in GPs' surgeries, than in the other countries;
• There are islands of excellence. For instance, at the Children's Hospital of the Vanderbilt University Medical Center in Nashville, USA, there is an EPR system for inpatients and outpatients. We saw a number of technologies, including StarChart which allows faster access to patient data such as lab results and radiology reports; and WizOrder, a "computer physician order entry system", which can help guide drug dosing for patients and check for allergies.[46] An online portal allows patients to access the results of most tests, and to send messages to their doctor;
• There are plans to introduce a summary electronic patient record in Canada and France. In Canada, CHI is overseeing the introduction of the 'Private Lifetime Record', which will include high level information about the patient's medical, medication and immunisation history, including diagnostic information such as X-rays and lab results. The information will be accessible from hospitals, community health centres and GP offices. Eventually, patients will be able to access their information from home.[47] In France, the national DMP will gather data from a range of local systems including hospitals, community providers and pharmacies into a single record. The DMP will include medical notes, images and prescription information and a section for patients to record information;[48] and
• Ensuring interoperability and consistent clinical information standards are important goals. In Canada, a range of local systems will continue to be used in hospitals and elsewhere, but they must be able to exchange information with the EPR. All information will be stored in coded form using SNOMED CT clinical codes. In France, the success of the DMP depends on organisations having local systems, such as that at Amiens, which can interact with the national system. There is a long way to go with this: for example, only a third of French hospitals have digital imaging systems. In the USA, Regional Health Information Organisations have been established to promote the sharing of information.

39. However, a significant difference between England and these other countries is that existing IT systems are being replaced by new IT systems purchased centrally by Connecting for Health on behalf of hospitals and other local organisations. This is possible largely because the majority of providers in England form part of the NHS. In France and Canada, independent healthcare providers will purchase their own systems which must be interoperable with national systems. In the US, the Certification Commission for Healthcare Information Technology aims to encourage healthcare providers to purchase accredited, interoperable systems.[49]

Conclusions

40. The National Programme for IT (NPfIT) is a complex and ambitious set of projects intended to transform the use of information technology in the NHS. At the heart of the programme is the NHS Care Records Service (NCRS), which aims to introduce a range of electronic patient record (EPR) systems. EPR systems offer significant potential improvements to the safety, quality and efficiency of care and are being implemented in most health systems in the developed world.

41. NPfIT is characterised by a centralised management structure and large-scale procurement from private suppliers. This approach aims to offer improved value for money and to address the previously patchy adoption of IT systems across the health service. The Department defended the progress made by NPfIT to date, arguing that the programme is on course to succeed. However, serious doubts have been raised, from sources including the Public Accounts Committee, about how much has been achieved and about the likely completion date. In particular, progress on the development of the NCRS has been questioned.

42. During our inquiry, both at home and abroad, similar messages were given to us repeatedly from different sources. We commend these to the Department:

• The EPR is essential and is the top priority for improving health care.
• The installation of a comprehensive IT system is a long journey best managed by a staged and piloted development not a big bang approach.
• The input of end-users is vital in planning, design and implementation.
• Local flexibility is essential to allowing continued use of effective systems already in place, as is interoperability if local systems are to communicate with one another.
• As EPR systems make more personal health data accessible to more people, breaches of security and confidentiality must be regarded as serious matters.
• The support of the public must be obtained. The fact that EPR systems are essential for the delivery of modern health care and can improve communication between different health care staff and between staff and patients must be adequately publicised to users of the NHS. We believe this would help to convince people of the necessity and benefits of the EPR and reduce resistance where it exists.

4   There have been some exceptions to this rule, for example the successful implementation of the Millennium system at Homerton and Newham hospitals in London and the installation of EPR systems at the Wirral Hospital - see Q 577. Back

5   Q 27 Back

6   Q 102 Back

7   NHS Executive, Information for Health: An Information Strategy for the Modern NHS 1998-2005, September 1998, p.110. The strategy set out 6 different levels of EPR to be achieved by hospitals, ranging from level 1, "Clinical Administrative data", through to level 6, "Advanced multimedia and telematics", p.37. Back

8   Department of Health, Delivering 21^st Century IT support for the NHS: national strategic programme, June 2002, p.1 Back

9   Ibid, p.1 Back

10   Ibid, p.i Back

11   Full details of the original specification for the NCRS, which also included a range of local clinical IT systems, can be found at National Programme for Information Technology, Output Based Specification Version Two, Integrated Care Records Service, 1 August 2003. Back

12   See Personal statement regarding Richard Granger, Connecting for Health press release, 6 June 2007 Back

13   Q 578 Back

14   Q 2 Back

15   Q 587 Back

16   Q 2 Back

17   See Changes to delivery of NHS National Programme for IT, Connecting for Health press release, 28 September 2006 Back

18   Q 256 Back

19   Q 376 Back

20   Q 389 Back

21   Ev 1 Back

22   Q 2 Back

23   Ev 47 Back

24   National Audit Office, Department of Health: The National Programme for IT in the NHS, HC 1173, 16 June 2006, p.6 Back

25   Ibid, p.4 Back

26   Ibid, pp.18-23 Back

27   Ev 9 Back

28   Public Accounts Committee, Twentieth Report of Session 2006-07, Department of Health: The National Programme for IT in the NHS, HC 390, pp.5-7 Back

29   Ibid, p.6 Back

30   National Audit Office, Department of Health: The National Programme for IT in the NHS, HC 1173, 16 June 2006, p.4 Back

31   Health Committee, Public Expenditure on Health and Personal Social Services 2006: Memorandum received from the Department of Health containing Replies to a Written Questionnaire from the Committee, HC 1692-i, p.102 Back

32   Public Accounts Committee, Twentieth Report of Session 2006-07, Department of Health: The National Programme for IT in the NHS, HC 390, p.5 Back

33   Ev 117 (HC 422-III) Back

34   See Ev 4-5: the Department of Health described the PDS as a "key component" of NCRS and stated that the system already transfers 6.5 million messages per week to and from users across the NHS. Back

35   The PDS replaces the National Strategic Tracing Service, which had many similar functions. Back

36   Ev 5 Back

37   Ev 117-118 (HC 422-III) Back

38   The exact data requirements for the DCR will need to be determined for each clinical specialty and standard datasets will need to be agreed. We discuss this further in Chapter 4. Back

39   Ev 5-6 Back

40   Ev 8 Back

41   Ev 12 Back

42   Q 35 Back

43   See www.infoway-inforoute.ca/en/home/home.aspx for more details Back

44   See www.d-m-p.org/ Back

45   See www.govtech.com/gt/91029 Back

46   For further details, see www.mc.vanderbilt.edu/ Back

47   See www.infoway-inforoute.ca/en/ValueToCanadians/EHR.aspx for more details about the Canadian "Private Lifetime Record" Back

48   For more information about the DMP, see www.d-m-p.org/demonstrateur/ Back

49   See www.cchit.org/about/ Back