MR GUY HAINS, PROFESSOR BRIAN RANDELL AND DR ROB HALE

10 MAY 2007

  Q260  Dr Taylor: It could be at either?

  Mr Hains: That is correct, as it is today and it operates through referrals, results and letters between the two.

  Q261  Dr Taylor: I take the Detailed Care Record to equate much more to the detailed hospital notes rather than the GP. I do not wish to be derogatory, but they can write only a very small amount. Will you take into account the detail in hospital notes?

  Mr Hains: The system in terms of being able to log both at free text and code level will reside as it does today in the software in hospital systems. That will reside in the location where that treatment takes place on the resident database. I need to make it clear that in terms of the deployments we have made to date this is not a single database. I shall talk a little later about the instances and systems that support that.

  Q262  Dr Taylor: As far as I am aware, hospital-based systems at the moment certainly include radiological and pathological results but not what I regard as the nitty-gritty of patient histories, physical examinations and contacts with relatives and details about the patient. How will you include those?

  Mr Hains: As to the full systems resident and available at the hospitals it is correct they are variable in terms of the amount of detail held. Some of it is in code form; some of it is in free text, and it is available for all the healthcare professionals in that hospital, if they have the correct and proper access rights to add to that record.

  Q263  Dr Taylor: Do you envisage that your Detailed Care Record will completely abolish the need for paper records?

  Mr Hains: As a technologist I think there will always be a need for reference to a file of original documents to be held, but the vast proportion of currently held records in not very secure environments generally in hospitals will be replaced by automation.

  Q264  Dr Taylor: I do not argue with that. Hospital notes are so difficult to find they are incredibly secure!

  Mr Hains: At the moment the simple answer is that individual hospitals can make their own decisions regarding how much data will be stored. The systems have the ability to capture and record that data electronically.

  Q265  Dr Taylor: Will they make their own decision whether or not to keep a paper record as well?

  Mr Hains: Yes, as indeed they do today.

  Q266  Dr Taylor: Practically speaking, we can see that the detail will remain in the paper file and there will be a certain amount of codified information on the computer system and that is really all there is?

  Mr Hains: Individual hospitals are making their own decisions regarding that. If one looks at, say, University Hospital Birmingham it has an advanced view; it wants to move to a very high level of electronically-stored records. Other hospitals may choose also to have a reference to paper-held records. We are not mandating the level of efficiency and automation to which those hospitals take their full records.

  Q267  Dr Taylor: Will the Detailed Care Record be held at the GP and hospital level?

  Mr Hains: Effectively, today most of the medical history will be at the GP level. When one goes to a hospital there will be rules-based access and controls as to who can add to and see that record, and the notes that go back to the GP are likely to be a summary of those outcomes. There will be a residual record regarding that episode held at the hospital with all the detail that takes place. Effectively, as it is today you will have the GP with his records and a hospital with the records of the details of the consultations and departmental activities that have taken place.

  Q268  Dr Taylor: Is it only the Summary Care Record that will be available nationally?

  Mr Hains: That is the current view. As has been discussed this morning, there are proposals to build upon aspects of the Summary Care Record in future, but at the moment that summary provides a very effective pointer and common reference to where data is held across what is a very complex environment. The answer is that the benefits of the Summary Care Record are in effect to provide consistency of data, to avoid duplication of records and effective electronic linking and connectivity across the health environment. Those who are using it attest to the value of that.

  Q269  Dr Taylor: How do you ensure that clinicians have input to what is in the Detailed Care Record?

  Mr Hains: In terms of the distinction between the national programme and its vision of a Detailed Care Record that is more a matter of policy. I am here to build the systems to support that. As to the sophistication of the systems that we are making available to hospitals, before we go anywhere near implementation we would work with clinical leads—administrators—to discuss what components, attributes and aspects of the system they want fully to exploit. The system's architecture and its ability to provide that connectivity is common, but there is a lot of local latitude as to how people want to use the systems, what particular emphasis they want the system to provide and, if you like, the depth of the data that they want to provide.

  Q270  Dr Taylor: Therefore, in the hospitals that you work with clinicians have a definite say as to what does and does not go into the Detailed Care Record?

  Mr Hains: Yes. Remember that in terms of our deployments to date we have been working on the patient administration system. With the recent implementation of Ipswich and others, we are moving out to support more of the clinical practices, but it is absolutely the clinicians who create the records. We work with expert user groups and reference groups because we want to keep a level of commonality in the deployed systems that we provide, but it is absolutely within their control in terms of the specification.

  Q271  Dr Taylor: Have you given specific thought to confidentiality and security?

  Mr Hains: Yes.

  Q272  Dr Taylor: How are you tackling that?

  Mr Hains: It works at a number of levels, but in terms of access security which is key the issuing of smart cards is not our responsibility but is really at the start of the life cycle of the security profile. That involves not just the card but effectively a PIN and how it is then implemented into our systems is very complicated. Therefore, individuals can have multiple roles and they can be multiple organisations. Your card is specific to how you operate in the NHS. Your access to data is limited strictly to the role you are performing at that time and the organisation for which you are doing it.

  Q273  Dr Taylor: I think we will come to smart cards in a bit more detail. Dr Hale, referring to the Detailed Care Record, what input into this have psychiatrists had round the country?

  Dr Hale: This is one of the problems. Speaking from the point of view of my own trust and the Royal College of Psychiatrists, we have not been able to make a great deal of input. Our experience is of learning about the design of the system as it develops. Obviously, there must be flexibility built into the design of the system that one must learn as one creates it in terms of what is appropriate, but there is a problem about taking into account the views of clinicians in the design.

  Q274  Dr Taylor: Would you insist on the psychiatric part of a Detailed Care Record to be entirely separate from the rest of the system as on the paper-based notes at the moment?

  Dr Hale: If it reflects current practice in most hospitals it would be separate, but obviously there are situations where the two have to be combined. That is obviously the case in, say, liaison psychiatry where one has a patient on a general medical ward who has a psychosomatic condition. In that case the psychiatric opinion is of direct relevance to the care of that patient. In those circumstances it is envisaged that one wants a system that reflects that sort of flexibility. There would be situations where they would be kept separate and situations where they would be combined.

  Q275  Dr Taylor: Is that something that you can take into account?

  Mr Hains: Yes. This may well be a matter of timing in terms of rolling it out to the different disciplines. We certainly want the input of expert groups as we effectively set the parameters for the system. In terms of the ability to control the visibility of data, some of it is clearly mandated by the national programme and some are inherent in our system. Inherent in the system that we are deploying—even to the extent of the point made this morning—we can suppress the name or address most relevantly for somebody who says that she is a concerned and battered wife who does not want her address visible as she makes her way round the healthcare system. We can do all of those things within the system. Clearly, we have been working not only with the issue of defined access to the systems. For us, in September there will be the establishment of the full legitimate relationship so that across organisations one will really be controlling who can see data. Most importantly—it is not just a footnote—the advantage of the technology is that one has a full audit trail of who has accessed the data which is not true of paper records. I believe that that is both a huge deterrent and, frankly, control as we go forward.

  Q276  Dr Taylor: Do you foresee that you will be combining existing computerised records that already exist? Will you be building on those?

  Mr Hains: Absolutely. One of the concerns that has been voiced is about the size and the endeavour of this programme. I would point to University Hospital Birmingham which is perhaps the largest one we have done, although Ipswich is probably close to it. We brought into the new system 10.2 million rows of customer data relating to existing patients. This was data that we had to go back and cleanse. Frankly, we had to take out thousands of duplicate records because of the level of computer sophistication in the prior system.

  Q277  Dr Taylor: So, this was on computer already?

  Mr Hains: Yes. We brought it across in order to make their system work and be operable. All of these systems require us to look at prior data and also interfaces between our core system and other systems that are operating. The deployments that we have done are voluntary on the part of the trusts that have chosen to take the system, so we have to satisfy them not only that we will not interrupt their day-to-day operations but that we can fully underwrite the implementation when it takes place. Needless to say, to satisfy them that we are carrying across all of their existing patient data is an absolute must.

  Q278  Dr Taylor: Was there much free text data on that?

  Mr Hains: I do not believe there was, but the fact that we are now interfacing to a lot of resident systems that are still there, which we will replace over time, ensures we have that connectivity to the departmental systems which have within them mainly free text data, so the answer is: yes, we have protected that.

  Q279  Dr Taylor: Professor Randell, do you have any comments on the security of patient records?

  Professor Randell: That is very much an open-ended question. A comment was made this morning about the inability in practice to have great scale and functionality and high security at the same time. I totally agree with that. Another point I stress is that the systems that we need to talk about are not just IT systems composed of hardware and software. The people involved in those systems are an incredibly important part of that. In saying that, I have in mind that I was involved in initiating a very large research project on the dependability of computer-based systems. When I say "dependability" I include reliability, safety and security. Most of the work on that project which involved five universities over six years turned out to be concerned with research on people with computers in the health area, although that was not the original plan. The sort of things that that project revealed was that when looking at issues of reliability and security the people were of crucial importance. They are both the source of problems and solutions. Typically, the medics are capable of achieving what they want to do despite if necessary the computer, and there are a number of very careful ethnographic studies within our project and many others which testify to that. I give a simple example of how a person can help. Bed management in a hospital may well be done by lying to the computer which is trying to do it naively. I am sure that we will get to more issues of human beings being the causes of losses of security and privacy. But the combination of scale, high security and complicated functionality and the role that people play means that we should not be talking just about computer systems and looking at how well those apparently work.