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Title and Description
National Health Service (NHS) Scotland Emergency Care Summary (ECS)
Reviewed/ candidate case
Quality reviewed case
Short description
The NHS Scotland Emergency Care Summary (ECS) system provides a summary of demographic, allergy and medication information for patients in Scotland from GP Practices. The ECS enables out of hours, A&E, and the national call centre clinicians access to important patient information in emergency care situations.
Objectives and purpose
The overall planned eHealth impact was to improve the safety of patient care. The newly developed NHS24 and OOH services had to be supported by providing access to summarised patient information about medications, allergies and adverse reactions. The ECS is part of the NHS Scotland eHealth strategy and part of the long-standing vision for a virtual EHR that can be accessed when it is needed for patient care in Scotland. It should be noted that saving cash or generating cash flow is not an objective of the project.
Detailed description
The ECS was first piloted in 2004. Since then, it has grown to be a national system across all 14 Health Board areas in Scotland covering over 5.3 million patients. All of the information for ECS is currently provided from primary care GP practice information systems. An extract from the GP patient record is sent to a national store twice a day. The dataset contains: * Patient demographics (address, telephone, Community Health Index (CHI) number – a unique patient identifier in use across Scotland) * Allergies and adverse reactions to medications * Medication history o Repeat prescriptions in past 12 months o Acute prescriptions in past 30 days * Consent flag o Patient opt out status The data is then accessed by healthcare professionals treating patients outside of the GP practice. Currently, four types of care organisations have the right to access the ECS: out of hours (OOH) services, accident and emergency (A&E), the national call centre for Scotland (NHS24), and the GPs themselves. Other user groups and services have already expressed their wish to receive access to the ECS in order to ease their work and improve patient safety. Ambulance services are scheduled to get access in the first half of 2009, and other user groups will be considered in the future. The architectural set up of the whole system is depicted in the figure below.
Further to the clinical uses, the audit reports enable effective monitoring of access patterns, thus ensuring any misuse is being identified in due time. GP practices can provide access to the ECS to patients by issuing print-outs when required. Information is sent to ECS by implied consent from the patient. However access to ECS is only by explicit consent only and the patient must give permission to the clinician before access to ECS is allowed. There are two paths of entry to the ECS. One is a web-portal where users are required to have a specific and separate user name and password. The web services route has been developed to enable access to ECS through an interface to the users main system and does not require a separate log in or password. All accesses made on ECS are recorded through a full audit trail that is available at all times to GP’s and Health Boards. The system is used by approximately 5000 physicians in hospital or community centres as, well as 2600 GPs for their own practice, 1000 nurses and 200 management staff. ECS connects a wide range of different organisations: over 1000 GP practices, 20 A&E departments, 20 acute receiving units with associated pharmacists, 30 OOH organisations with nursing and medical staff, and the national call centre NHS24, with the regional NHS24 hubs.
Costs of the ECS were financed from an allocation of funds from the Scottish Executive Health Department (SEHD). The ECS budget lines in the national ICT programme provide for: * Investment humps * Continuing operation * Maintenance * Project staff Financing packages for ECS development are financed by the Scottish Executive Health Department (SEHD) annual eHealth budget.
Interoperability and standards
The ECS does not create or capture new information about patients; it collects a summary of patient data that already exists in all EPR systems used by GP practices and makes it available to users who need it, but did not compile it. The patient information is updated twice a day.
Interoperability is at the core of ECS, and standards are in place throughout to ensure that the information is extracted in a standardised form. This is completed using xml schemas and standard security protocols (SOAP) for all messages.
Security and Audit standards are also in place and were nationally agreed at the start of the project.
Standards for recording medication and prescription information are agreed for the whole UK. They are set by the General Medical Council (GMC) in agreement with Department of Health and recognised professional clinical bodies. Scotland also has a National Clinical Dataset Development Programme (NCDDP) in place to identify and agree standards across all clinical ICT systems.
Patient and GP identifiers rely on existing unique codes. Patient and GP identifiers are taken from the NHS Scotland national patient identifier database known as CHI (Community Health Index).
Timescale
Start of planning
2002
1st milestone
2003: ECS project formally started. Engagement consultation and discussion with stakeholders at this stage was critical to the longer term success of the project.
2nd milestone
2005: In March, the ECS pilot was started in NHS Ayrshire & Arran Health Board and NHS Grampian Health Board. OOH clinicians were the main users in the early stages with A&E clinical use in place for Ayrshire and Arran. In October, the ECS pilot was evaluated and a decision made to continue and proceed to national rollout.
3rd milestone
2007: In July, cross Health Board access was available nationally, enabling all ECS records to be available in Scotland and a national launch of cross border audit processes. NHS24 go live with fully integrated access.
Start of routine operation
2006
Evaluation
In the past
Ongoing
In the future
Characteristic of the application
Country
United Kingdom
Part in the healthcare chain
Diagnosis
Therapy
Level of Implementation
Country-wide
Technology
Commercial solution - proprietary
Details on Technology
The implementation of ECS builds on existing systems and tools, like: * CHI as a unique patient identifier * The SCI Store as a foundation to the central national store for ECS * An existing data transport software, eLinks * GP practice systems to generate and maintain files of patient ECS information using the Scottish Enhanced Functionality (SEF) process * The NHS N3 broadband network.
Codes are not particularly important for ECS. Most data is mainly a free text view at all four interfaces with the different GP systems: GPASS, InPS, EMIS and Ascribe. An XML schema is extracted from GP systems twice each day.
System-to-system integration is in place for Adastra and Taycare at OOH and the Patient Relationship Management (PRM) version 2 software used by NHS24. A&E Integration is due in 2009. Web access for audit is in place for A&E, OOH admin and system admin at each Health Board.
The SCI Store used as the basis for ECS is a Microsoft SQL Server database with several plug-ins developed as web applications using Active Server Pages and Visual Basic scripts. The Atos Origin Alliance, as part of the national IM+T contract for NHS Scotland have developed and maintained the SCI Store since 2001 and ECS store since 2004. All information held on the central ECS Store is held in a managed central data centre in Scotland.
Results
Outcomes
In 2008, over 98% of GP practices participate fully in ECS, and 99.% of the population have an ECS record. Total utilisation in 2008 is estimated at about 120,000 accesses per month. Peaks are consistent with a high number of GP practices being closed at Easter and Christmas, as seen in the chart below.
An EHR IMPACT evaluation estimated that annual net benefits are realised by 2008, seven years after planning started and five years after initial implementation in the two pilot sites. ECS should show a positive and increasing net benefit in 2012. In 2007, the annual net benefit to costs ratio is slightly positive and rises to +2.6 at year nine, 2010. The cumulative ratio in 2010 is a slight negative at -0.2, but has reduced steadily over the previous four years, when it exceeded -0.8, showing the potential to switch into a positive in 2012.
The initial over-arching benefit was better patient safety. The main benefits are realised for patients accessing NHS24, OOH and A&E services. Without ECS, it is recognised that services would be of lower quality and there would be an increased risk of medication errors due to wrong or missing information, leading to avoidable negative impacts on patients.
Wider impact
Clinicians at NHS24 and OOH benefit as they have access to valid, current and reliable patient information. GP’s benefit through the reduction in calls to GP Practices about patient medication during normal working hours, as well as providing information to Out of Hours Services.
The EHR IMPACT analyses show a financial position where extra cash of some £5.5 million has been invested over nine years to realise non-financial benefits and redeployed finance of over £21.6 million. These are equivalent to gross returns of some 30% for society at large, not for an individual stakeholder. As common among such eHealth initiatives, the purely financial impact is negative. The investment is justified by improved patient safety and quality of care, as well as improvements in efficiency and effectiveness, but no cash inflow should be expected.
The NHS Scotland has gained an estimated 38% of the benefits, a positive impact exceeding £8 million, with citizens also gaining 37%, slightly less than £8 million. This is attributed mainly to reductions in risk exposure. Healthcare professionals as individuals have about a quarter of the benefits.
Estimated costs are distributed mainly between healthcare professionals and HPOs, with no costs for citizens.
Results expected?
The primary objective of the ECS was a contribution to patient safety. Thus, the outcomes and benefits are inline with expectations. This also holds for the financial impact, since cash savings or generating cash flow are not objectives of ECS.
Success factors
Engagement Engagement with all stakeholders before design is complete and implementation begins is critical. The largest single estimated cost, over 50%, was the time of clinicians needed for engagement, compared to only 10% for ICT.
Patient communication The ECS project put in place national communication strategies to ensure that patients were informed about the project. Patient are also asked for permission before ECS is accessed, ensuring that the appropriate consent processes are followed, and patients are fully engaged in the process.
Rollout Approach An incremental roll-out was adopted for the national rollout of ECS. Decisions to participate were left to each of the 14 Health Boards so they could implement ECS at their own pace and when they judged their own motivation and interest as appropriate. Net benefits for the project are expected to occur in the tenth year of the project.
Goals Focusing on delivering benefits, not IT systems was another key to success. Also, the benefits were defined appropriately: patient safety, quality, risk reduction, and efficiency; not cash.
Failure factors
Acceleration of project rollout These are not short term, quick projects. They affect healthcare professionals, who have an essential role in securing success, across a whole country; it takes time. The alternative is achieving failure faster. Attempting to short-cut engagement usually leads to disrupted and increased investment with even longer timescales to net benefit.
Consultation Vs engagement The ECS evaluation shows that NHS Scotland goes beyond a narrow view of consultation and into effective engagement with stakeholders. There are several differences. Engagement has less defined and longer time horizons than consultation. Engagement gives stakeholders more ownership of the agenda. Engagement is more likely to result in a well-formed outcome over an eHealth investment life-cycle.
Transferability of evaluation results Extrapolating the ECS cost benefit profile to the whole NHS Scotland eHealth strategy will not be reliable. Engagement may be more complex, risks will be higher, the ICT more complicated and changes to working and clinical practices more demanding. The established approach by NHS Scotland should enable the natural eHealth life-cycles to be pursued.
References
References and dissemination
Gartner Industry Research (2007): Case study: Scotland’s Emergency Care Summary is a first step toward a national health information exchange, 29 June 2007, pp 1-7.
NHS Scotland Scottish Government Health Department (2008): eHealth Strategy 2008 – 2011. 1 July 2008.
The Scottish Executive Health Department in cooperation with Health Rights Information Scotland: 'How to see your health records' and 'Confidentiality - it's your right'
The Scottish Executive Health Department, in cooperation with Health Rights Information Scotland (2006): Your Emergency Care Summary. What does it mean for you?, available at: www.scotland.gov.uk/Publications/2006/08/16152132/0 (October 2008)
EHR IMPACT study for EC, DG INFSO: The socio-economic impact of NHS Scotland’s Emergency Care Summary, www.ehr-impact.eu
ECS was runner up in GC Awards for Innovation – Best project Government to Citizen.
Languages
English
Organisation implementing
Title
Mr
Forename
Jonathan
Surname
Cameron
Organisation
NHS National Services Scotland
Department
National Information Services Group
Occupational background
Department Head, Supervisor, Director, President
Address of organisation
Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB United Kingdom
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