1. Murray, Peter J.

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I can see you, sitting there and thinking "Why should I, a nurse in the United States (or Canada or Australia), wish to read about information management in someone else's health service?" Several possible answers come to mind; one is that I believe many nurses genuinely are interested in learning about, and possibly using ideas from, nursing and health care settings in parts of the world other than their own. A more practical, although not necessarily more important, reason is that there seem to be common issues arising in nursing and health care informatics in many countries. Although not all readers of this journal subscribe to the nursing discussion groups on the Internet, those who do will probably have noticed some of the discussion that has taken place in recent months around issues such as, for example, clinical information systems, electronic patient records, and strategies for teaching informatics in nursing curricula. As a contribution to the exchange of information and ideas, I felt it would be useful to provide a brief overview of the key elements of the National Health Service (NHS) Information Management and Technology (IM&T) Strategy, and some of the issues raised for nurses.


There is not space here to provide a comprehensive explanation of the structure of the NHS, but I should give a little explanation of its organization and funding to provide the context. The aim of the NHS, founded in 1948, is to provide health care services to all members of the population according to need, free at the point of delivery, and funded from national tax revenues. In US terms, I have commonly heard it described as "socialized medicine," although many of the recent changes in organization, particularly to a more business-oriented approach to service provision, finance, and management, have rendered aspects akin to parts of the US system. Whereas much of the work of the NHS still is based in acute general hospitals of varying sizes and range of speciality services, more care is being provided by community-based nurses and under the remit of General Practitioners (community-based family doctors). The IM&T strategy seeks to facilitate communication between not only all of these bodies but also with the nationally and regionally based authorities involved in coordination of services.


The IM&T strategy was launched in 1992. It is based on several principles, which include the requirements that information should:


* Be person-based;


* Focus on health;


* Be capable of being shared across all parts of the NHS;


* Be confidential and secure; and


* That systems should support management and organizational change.



The strategy should be seen within the context of many of the other major changes that have occurred within the NHS in recent years, which include:


The "Health of the Nation" Targets. Based in large part on the World Health Organization "Health for All by 2000" goals, these targets identify key areas, such as heart disease, cancer, mental health, and teenage smoking. The aims of the targets are to reduce ill health and deaths through a mix of health education, health promotion, and clinical interventions.


The "Patients' Charter." This document sets standards for patients' expectations in relation to waiting times for outpatient appointments, inpatient admissions, etc., and requires systems for hospitals to monitor achievement of the standards.


"Care in the Community." This initiative has required the coordination of community-based services by NHS organizations and Local Authority Social Services.



A number of key infrastructure projects are designed to support the strategy, some of which have been completed; others are in the early stages or developing demonstration sites. Among the major projects of the IM&T are:


* The creation of an NHS-wide (ie, national) electronic network that will enable all parts of the NHS to communicate with each other, and provide secure, efficient, and cost-effective communications and data transfer;


* The development of new NHS numbers, to provide each person with a unique identifier to facilitate data exchange;


* The development of a thesaurus of terms used within each profession to record and communicate patient care and to assist in data capture;


* The creation of national standards for electronic communications, data formats, and quality control; and


* The development of electronic patient records, which will be generic, multidisciplinary documents.



The first new NHS numbers will be issued to babies by the Registrars of Births and Deaths in December 1995, and the plan is that they will be in widespread use by much of the population by late 1996. Concerns have been raised, however, about the lack of public awareness and debate on the scheme, with fears expressed on civil liberties grounds, that the Government is seeking to introduce, by the back door, a de facto national identity card scheme. The clinical terms project for nursing, midwifery, and health visiting have produced their thesaurus of terms that will now be piloted. However, progress on other projects has been slower, sometimes of necessity.


The NHS-wide network, described by some as an "information superhighway or Internet for the NHS," is one of the key elements in the strategy, and as with the wider Internet, has been subject to a great deal of hype and discussion. The aim of the network is to allow for large scale electronic communications, which eventually will influence clinical practices, as well as administrative, in the same way that many see the increased use of the Internet influencing the way many people in other areas work. The transmission of e-mail and electronic data interchange between all parts of the NHS will be for administrative purposes, and will also include patient-related information. The "spine" of the NHS-wide network, with dazzling imagination called HealthNet, was formally launched in October 1995. With only 30 NHS organizations linked into it at the time of launch, HealthNet uses the same TCP/IP protocol as the Internet.


If electronically stored and transmitted confidential patient data are accessible from any one of thousands of terminals around the country, and by any one of hundreds of thousands of legitimate users, the security implications and possibilities of deliberate or accidental misuse are enormous. It is a range of these issues that is currently causing most concern within some areas of the health care professions. A secure "firewall" will be installed, to allow users of the network to access services and information on the wider Internet, but not allow hacking in to information from outside. However, given the ease with which Netscape's security codes were hacked recently, I would not be too confident of the integrity of the "firewall."


A more common problem, given nurses' general attitudes to information technology is given by the following scenario. A prominent local politician has been admitted to hospital and journalists have been trying to obtain information about his health care history; one journalist has even been caught in a stolen doctor's coat. A nurse in the hospital is using a terminal to update a patient's care plan when she is suddenly called away to deal with a cardiac arrest; she does not shut down the terminal, and the access codes for half the ward staff are stuck to the side of the terminal on scraps of paper. I leave the rest to your imagination.


The medical professions in particular have expressed concern about security and confidentiality issues in relation to patient information, and have lobbied hard in favor of data encryption; this is being resisted strongly by, among others, the Department of Health, and other more covert government agencies. The nursing profession seems to have been very quiet on this and several other issues; whether this reflects lack of concern or of expertise to debate the issues remains to be seen.


The recent conference of the Nursing Specialist Group of the British Computer Society addressed issues around security and confidentiality of patient data, but in addition the profession has been attempting to influence the development of the strategy, and wider issues relating to IM&T, through SAGNIS, the Strategic Advisory Group for Nursing Information Systems. This group, chaired by the Chief Nursing Officer for England, and with various representatives from the profession, has identified three priority areas:


1. The development of person-centered information systems, which must be capable of supporting the profession at the point of care delivery and clinical decision-making.


2. The development of the thesaurus of terms, to be used for care planning, shared records, audit, and minimum data sets.


3. The inclusion of informatics in the mainstream of nurse education.



As previously indicated, the terms project is now complete and the thesaurus is being piloted, while work seems to be ongoing to attempt to influence the nature of information systems. The inclusion of informatics in the curriculum, beyond the level of basic keyboard skills is more problematic, particularly given the general level of computer illiteracy among faculty members in schools and colleges of nursing. An ongoing series of workshops is addressing the integration of informatics into the curriculum, and a number of schools have produced useful material, although rather than being adopted widely, it may suffer from the "not invented here" syndrome.


The changing political climate (there will be a general election in the United Kingdom within 18 months at most) means that some of the more politically sensitive components of the strategy may start to suffer from some "back-pedaling." We live in interesting times as far as nursing and health care informatics are concerned, in the United Kingdom as elsewhere. The commonality of issues in many countries suggests we should be exploring, if not common approaches, at least exchange of ideas, information, problems and solutions, or risk once again being pushed aside as doctors and administrators dictate the nature and the pace of in formatics development.