The largest study of the national roll-out of the NHS Care Records Service to date has concluded that its top down, standardised approach has led to much slower progress than originally envisaged.
The study, led by Professor Aziz Sheik from the University of Edinburgh, says the original approach of the National Programme for IT in the NHS has had to evolve to "admit more variation and greater local choice."
It says that further implementation will be a “long, complex and iterative process requiring flexibility and local adaptability, both with respect to the system and the implementation strategy.”
It adds that whilst there is no clear evidence that a “middle out approach” will achieve the programme’s goals, experience suggests that neither a purely top-down nor a purely bottom-up approach is likely to do so.
The study, which is published in today’s British Medical Journal, was conducted by researchers from four British universities.
It looked at the experiences of five ‘first-wave’ implementation sites for NPfIT electronic health record systems.
These comprised one Cerner Millennium site, one RiO site and three Lorenzo sites, although some took only element of a system or only took it for a specific department.
The researchers examined documents and undertook observerations and interviews to determine the impact of the systems, and found "considerable delays and frustrations."
Despite this, they say that “support for electronic health records remains strong, including from NHS clinicians."
However, they also note that clinical enthusiasm tends to be generated by benefits in their immediate area of work "not necessarily to the benefits that would come from geographically widespread sharing of patient data."
The study finds that the central contracts negotiated by the national programme in 2002 have led to a number of adverse consequences.
“These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities.”
After reviewing alternative approaches from Europe, North America, Australia and elsewhere, it concludes that a "middle-out" approach should be tried, which “combines government direction with increased local autonomy and for restricting detailed electronic health record sharing to local health communities."
The study makes four specific, policy related recommendations. These start with a need for fundamental questions to be asked and answered about what the country needs and what the country wants to pay for.
It also identifies a need for the Department of Health to provide clear information on the future of NPfIT and provide consistency in its leadership.
In addition, its says that trusts should be allowed to “communicate changing local and national NHS priorities directly to those working with them” and that linking contract payments to more “thoughtfully agreed outcomes” could potentially control costs and benefit both NHS trusts local service providers.
The researchers are now undertaking a longer term, multi-site case study evaluating data collection that is due to end in 2011.