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The demand for accurate data to measure improvement in the quality and delivery of NHS services has never been greater. In a constrained financial climate this places a significant burden on organisations. Increasingly the inability to contribute such data in itself is seen as failure for organisations irrespective of their performance. The data demand varies widely from well-known regulatory performance standards that demonstrate the length of time it takes for patients to receive treatment (where 4 hours in emergency settings is the hospital standard or 18 weeks in elective care when a patient is referred by a GP) to outcome measures such as numbers of patients acquiring infections in hospital. These measures have been driven by changes in policy over a number of years and are designed to set a minimum set of standards that the public can expect.
Back in February, the Francis Report exposed the deficiencies of the Mid Staffordshire trust and stressed the need for more accurate, useful and relevant information. Important information on mortality such as Hospital Standardised Mortality Ratios (HSMR) and Summary Hospital-Level Mortality Indicators (SHMI) for example, has been brought into common public use. These sorts of measurements are not just a hospital requirement but are at the heart of every sector. Primary care and community, mental health and ambulance services each have their own minimum standards.
The need for openness
Increasingly, data and reporting about the medical performance of services is developing. The HSCIC reports and publishes data on over 50 different elements of services. Indeed much if not all of this has been driven by medical professional effort to drive improvement in their own areas of interest. Support from the medical colleges has been essential in driving this process as well as ensuring engagement from doctors themselves. The public expect to be able to see this data and current national policy is driving this development even more widely and to increasing levels of detail. In a move that was deemed a ‘major breakthrough’ in NHS transparency, NHS England published data on the mortality rates of a number of common surgical procedures, not at hospital level, but rather at named consultant level. This is not new – cardiac surgery mortality rates have been published at consultant level for a number of years and the process to get there was a very difficult one for the individuals involved.
As more such data is made available, the need for public policy to continue moving toward full openness and disclosure with data will only increase. Indeed, NHS national director for patients and information Tim Kelsey has been very clear about the need for complete data covering the whole of the medical record to be submitted by hospitals in the next couple of years. This includes information covering prescribed medicines at patient level from hospitals; an ask that will stretch many institutions.
So what are institutions to do? There is pressure to support clinicians to accurately record detailed clinical information, as well as pressure to submit increasing numbers of national datasets speedily. Without substantial informatics infrastructure in hospitals we will not be able to properly support our clinical staff and rendering us unable to fully report our clinical performance. More importantly, the public will not have the information on which to form a view and we will have let them down.
The policy from 2002 was to computerise the hospital medical record via the National Programme for IT, but this has failed at the national level. Of course there are hospitals that stand out but these are exceptions.
If instead of using measurement to assess clinical care we use measurement to assess the maturity of our hospital information systems and ask ourselves just one question, how many hospitals have achieved HIMSS level 7 in the English National Health Service, the answer is none.
Most other European countries have at least achieved this in one hospital and in North America multiple times. GP practices have for the most part completely computerised their record and a normal part of every GPs job is to code the record in real time. This has happened over a number of years and was in part driven by incentives.
Incentives are now no longer on the table – the emphasis is instead on a mechanism which will penalise if clinical performance is poor, with more severe penalties where data is not provided. I do not know what the public view of this is but I know as a patient myself that I expect no less than this. For hospitals and clinicians we now have to provide a comprehensive electronic record and systems that clinicians will use in real time. Our connectedness with other parts of the healthcare system and with patients is also an essential requirement.
The challenge ahead
Let us not underestimate the difficulty of achieving a comprehensive electronic hospital record or the prolonged effort required. Only from the knowledge that the data is accurate and the ability to provide real time data for clinicians on demand will we be successful in supporting our clinicians.
I firmly believe that hospitals that achieve this position in the next couple of years will be the ones that succeed in the long term. We are at a tipping point brought about by public expectation, public policy and fiscal restraint, but let us ensure we invest our scarce pounds in clinical informatics infrastructure to support clinical improvement.
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