England’s Electronic Prescription Service: Infrastructure in an Institutional Setting

We describe the development of the Electronic Prescription Service (EPS), the solution for the electronic transmission of prescriptions adopted by the English NHS for primary care. The chapter is based on both an analysis of data collected as part of a nationally commissioned evaluation of EPS, and on reports of contemporary developments in the service. Drawing on the notion of an installed infrastructural base, we illustrate how EPS has been assembled within a rich institutional and organizational context including causal pasts, contemporary practices and policy visions. This process of assembly is traced using three perspectives; as the realization and negotiation of constraints found in the wider NHS context, as a response to inertia arising from limited resources and weak incentive structures, and as a purposive fidelity to the existing institutional cultures of the NHS. The chapter concludes by reflecting on the significance of this analysis for notions of an installed base

Development and formative evaluation of the e-Health implementation toolkit

<b>Background</b> The use of Information and Communication Technology (ICT) or e-Health is seen as essential for a modern, cost-effective health service. However, there are well documented problems with implementation of e-Health initiatives, despite the existence of a great deal of research into how best to implement e-Health (an example of the gap between research and practice). This paper reports on the development and formative evaluation of an e-Health Implementation Toolkit (e-HIT) which aims to summarise and synthesise new and existing research on implementation of e-Health initiatives, and present it to senior managers in a user-friendly format.<p></p> <b>Results</b> The content of the e-HIT was derived by combining data from a systematic review of reviews of barriers and facilitators to implementation of e-Health initiatives with qualitative data derived from interviews of "implementers", that is people who had been charged with implementing an e-Health initiative. These data were summarised, synthesised and combined with the constructs from the Normalisation Process Model. The software for the toolkit was developed by a commercial company (RocketScience). Formative evaluation was undertaken by obtaining user feedback. There are three components to the toolkit - a section on background and instructions for use aimed at novice users; the toolkit itself; and the report generated by completing the toolkit. It is available to download from http://www.ucl.ac.uk/pcph/research/ehealth/documents/e-HIT.xls<p></p> <b>Conclusions</b> The e-HIT shows potential as a tool for enhancing future e-Health implementations. Further work is needed to make it fully web-enabled, and to determine its predictive potential for future implementations

A national analysis of trends, outcomes and volume-outcomes relationships in thyroid surgery

OBJECTIVES: Thyroid conditions are common and their incidence is increasing. Surgery is the mainstay treatment for many thyroid conditions, and understanding its utilisation trends and morbidity are central to improving patient care. DESIGN: An N=near-all analysis of the English administrative dataset to identify trends in thyroid surgery specialisation, volume-outcome relationships, and the incidence and risk factors for short- and long-term morbidity. MAIN OUTCOME MEASURES: Between 2004 and 2012, 72594 patients underwent elective thyroidectomy in England. Information about age, sex, morbidities, thyroid disease and surgery, adjuvant treatments, and complications including hypocalcaemia and vocal palsy were recorded. RESULTS: Mean age at surgery was 49±30 and a female predominance (82%) was observed. Most patients underwent hemithyroidectomy (51%) or total thyroidectomy (32%). Patients underwent surgery for benign (52.5%), benign inflammatory (21%), and malignant (17%) thyroid diseases. Thyroid surgery grew by 2.9% a year and increased in specialization. Increased surgeon volume significantly reduced lengths of stay: the proportion of length of stay outliers fell from 11.8% for patients of occasional thyroidectomists (50 thyroidectomies a year). Post-discharge vocal palsy and hypocalcaemia occurred in 1.87% and 1.58% of cases respectively. High-volume surgeons had a reduced incidence of vocal palsy and volumes >30 were consistently protective. CONCLUSIONS: Thyroid surgery is increasingly specialised. High-volume surgeons achieve lower complications rates, including lower vocal palsy rates, and length of stay. This article is protected by copyright. All rights reserved

Primary care capitation payments in the UK. An observational study

<p>Abstract</p> <p>Background</p> <p>In 2004 an allocation formula for primary care services was introduced in England and Wales so practices would receive equitable pay. Modifications were made to this formula to enable local health authorities to pay practices.</p> <p>Similar pay formulae were introduced in Scotland and Northern Ireland, but these are unique to the country and therefore could not be included in this study.</p> <p>Objective</p> <p>To examine the extent to which the Global Sum, and modifications to the original formula, determine practice funding.</p> <p>Methods</p> <p>The allocation formula determines basic practice income, the Global Sum. We compared practice Global Sum entitlements using the original and the modified allocation formula calculations.</p> <p>Practices receive an income supplement if Global Sum payments were below historic income in 2004. We examined current overall funding levels to estimate what the effect will be when the income supplements are removed.</p> <p>Results</p> <p>Virtually every Welsh and English practice (97%) received income supplements in 2004. Without the modifications to the formula only 72% of Welsh practices would have needed supplements. No appreciable change would have occurred in England.</p> <p>The formula modifications increased the Global Sum for 99.5% of English practices, while it reduced entitlement for every Welsh practice.</p> <p>In 2008 Welsh practices received approximately £6.15 (9%) less funding per patient per year than an identical English practice. This deficit will increase to 11.2% when the Minimum Practice Income Guarantee is abolished.</p> <p>Conclusions</p> <p>Identical practices in different UK countries do not receive equitable pay. The pay method disadvantages Wales where the population is older and has higher health needs.</p

Data linkage errors in hospital administrative data when applying a pseudonymisation algorithm to paediatric intensive care records.

OBJECTIVES: Our aim was to estimate the rate of data linkage error in Hospital Episode Statistics (HES) by testing the HESID pseudoanonymisation algorithm against a reference standard, in a national registry of paediatric intensive care records. SETTING: The Paediatric Intensive Care Audit Network (PICANet) database, covering 33 paediatric intensive care units in England, Scotland and Wales. PARTICIPANTS: Data from infants and young people aged 0-19 years admitted between 1 January 2004 and 21 February 2014. PRIMARY AND SECONDARY OUTCOME MEASURES: PICANet admission records were classified as matches (records belonging to the same patient who had been readmitted) or non-matches (records belonging to different patients) after applying the HESID algorithm to PICANet records. False-match and missed-match rates were calculated by comparing results of the HESID algorithm with the reference standard PICANet ID. The effect of linkage errors on readmission rate was evaluated. RESULTS: Of 166,406 admissions, 88,596 were true matches (where the same patient had been readmitted). The HESID pseudonymisation algorithm produced few false matches (n=176/77,810; 0.2%) but a larger proportion of missed matches (n=3609/88,596; 4.1%). The true readmission rate was underestimated by 3.8% due to linkage errors. Patients who were younger, male, from Asian/Black/Other ethnic groups (vs White) were more likely to experience a false match. Missed matches were more common for younger patients, for Asian/Black/Other ethnic groups (vs White) and for patients whose records had missing data. CONCLUSIONS: The deterministic algorithm used to link all episodes of hospital care for the same patient in England has a high missed match rate which underestimates the true readmission rate and will produce biased analyses. To reduce linkage error, pseudoanonymisation algorithms need to be validated against good quality reference standards. Pseudonymisation of data 'at source' does not itself address errors in patient identifiers and the impact these errors have on data linkage.Economic and Social Research Council (ESRC) National Centre for Research Methods (NCRM), grant number ES/F035098/1

Variations in cardiovascular disease under-diagnosis in England: national cross-sectional spatial analysis

BACKGROUND: There is under-diagnosis of cardiovascular disease (CVD) in the English population, despite financial incentives to encourage general practices to register new cases. We compared the modelled (expected) and diagnosed (observed) prevalence of three cardiovascular conditions- coronary heart disease (CHD), hypertension and stroke- at local level, their geographical variation, and population and healthcare predictors which might influence diagnosis. METHODS: Cross-sectional observational study in all English local authorities (351) and general practices (8,372) comparing model-based expected prevalence with diagnosed prevalence on practice disease registers. Spatial analyses were used to identify geographic clusters and variation in regression relationships. RESULTS: A total of 9,682,176 patients were on practice CHD, stroke and transient ischaemic attack, and hypertension registers. There was wide spatial variation in observed: expected prevalence ratios for all three diseases, with less than five per cent of expected cases diagnosed in some areas. London and the surrounding area showed statistically significant discrepancies in observed: expected prevalence ratios, with observed prevalence much lower than the epidemiological models predicted. The addition of general practitioner supply as a variable yielded stronger regression results for all three conditions. CONCLUSIONS: Despite almost universal access to free primary healthcare, there may be significant and highly variable under-diagnosis of CVD across England, which can be partially explained by persistent inequity in GP supply. Disease management studies should consider the possible impact of under-diagnosis on population health outcomes. Compared to classical regression modelling, spatial analytic techniques can provide additional information on risk factors for under-diagnosis, and can suggest where healthcare resources may be most needed

Integrated Personal Health Records: Transformative Tools for Consumer-Centric Care

<p>Abstract</p> <p>Background</p> <p>Integrated personal health records (PHRs) offer significant potential to stimulate transformational changes in health care delivery and self-care by patients. In 2006, an invitational roundtable sponsored by Kaiser Permanente Institute, the American Medical Informatics Association, and the Agency for Healthcare Research and Quality was held to identify the transformative potential of PHRs, as well as barriers to realizing this potential and a framework for action to move them closer to the health care mainstream. This paper highlights and builds on the insights shared during the roundtable.</p> <p>Discussion</p> <p>While there is a spectrum of dominant PHR models, (standalone, tethered, integrated), the authors state that only the integrated model has true transformative potential to strengthen consumers' ability to manage their own health care. Integrated PHRs improve the quality, completeness, depth, and accessibility of health information provided by patients; enable facile communication between patients and providers; provide access to health knowledge for patients; ensure portability of medical records and other personal health information; and incorporate auto-population of content. Numerous factors impede widespread adoption of integrated PHRs: obstacles in the health care system/culture; issues of consumer confidence and trust; lack of technical standards for interoperability; lack of HIT infrastructure; the digital divide; uncertain value realization/ROI; and uncertain market demand. Recent efforts have led to progress on standards for integrated PHRs, and government agencies and private companies are offering different models to consumers, but substantial obstacles remain to be addressed. Immediate steps to advance integrated PHRs should include sharing existing knowledge and expanding knowledge about them, building on existing efforts, and continuing dialogue among public and private sector stakeholders.</p> <p>Summary</p> <p>Integrated PHRs promote active, ongoing patient collaboration in care delivery and decision making. With some exceptions, however, the integrated PHR model is still a theoretical framework for consumer-centric health care. The authors pose questions that need to be answered so that the field can move forward to realize the potential of integrated PHRs. How can integrated PHRs be moved from concept to practical application? Would a coordinating body expedite this progress? How can existing initiatives and policy levers serve as catalysts to advance integrated PHRs?</p

Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study

BackgroundPain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.Aims and objectivesTwo studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.MethodsFor the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.ResultsData from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.LimitationsGrey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.ConclusionsNo single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts